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SPRING 2003 

yard Mediral 



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Spurred by harsh economic reahtie^, 
physicjans are reassesskig their profession'^ 
and kitienting their own loss of freedom %*> 

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J Artassacnusem »jenerai 

Hospital, Henry Beecher ' 
occupied the first endowed 
chair of anesthesiology in 
the United States. Among \ 
many accomplishments were 
his observation of the placebo 
effect and his advocacy of 
informed consent rules for 
ethical clinical research. 

SPRING 2003 • \ 11 I I.! M I; 76, NUMBER 4 



Letters 3 

Pulse 5 

The Second Year Show, bringing 
medicine to Ufe, a new medical 
education dean, U.S. News and W brki 
Report rankings 

President's Report 8 


Editorial 9 

How far should physicians go to 
advocate for their patients? 
by And Wcissman 

Bookmark 10 

A re\icv\ by Elissa Ely of The Trojan 
Women: A Play by Euripides 

Bookshelf 11 

Benchmarks 12 

The pressure cooker of preeclampsia; 
the eyes have it with Alzheimer's 

Alumnus Profile 54 

Robots who cha cha provide 
disabled children with important 
creati\'e outlets, by Susan Cassidy 

Class N otes 56 

InMemoriam 60 

Harold Amos 

Obituaries 61 


Mamas, Don't Let Your Babies Grow Up to Be Doctors 14 

Corralled by increasing financial constraints and a loss of autonomy, some 
physicians are reassessing their career choices. /)v n t v e r l y b a l l a r o 

A Fistful of Dollars 22 

Physicians and economists share perspectives on how to cure what ails 
the current health care system. 

The Doctor's Lament 28 

An intermst linds her idcithstic vision of the healing art of medicine cut 
short by hard economic realities, bv v i r g i n i a l a t h a m 

Six Degrees of Innovation 32 

A small hut growing ntimber ol graduates are exploring new frontiers 
dong the border between medicine and business, by susan cassidy 


Return of the Native 38 

A surgeon tinds liis introduction to medical practice in his ancient 
homeland eased by the wisdom of his Harvard Medical School professors. 

by F A R R o K n S A I D I 

Heavy Metal 44 

A physician recalls patient encounters with metals, from gold 
injections to arsenic doses, by donald w. bickley 

Midwifery and Medicine 48 

Despite haunting tragedy, obstetrical pioneer Walter Channing 
created an enduring legacy of compassion, by a m a l i e m . k a s s 

Cover photograph: Christopher Hurting 

Harvarrl Merlinal 


In This Issue 



mcdicLil knowledge and practice. This is no less true now than it has 
been for the better part of human history, although before around 1900 
wealth was a largely nonspecific factor promoting health. Since then 
medical care has become an intrinsically valuable commodity, not just a risky and 
unpleasant form of conspicuous consumption (just how risky and unpleasant is 
compellingly conveyed in the excellent play and film The Madness of King George). 

In the capitalist democracy that has evoh'ed from King George's rebellious 
colonies, the rising costs of medicine are precipitating a crisis that is unlikely to 
resolve itself in the easily foreseeable future, for reasons both economic and politi 
cal. To begin with, medical care is consuming an increasing fraction of the GDP. 
This may or may not be a bad thing. At a cost approaching 15 percent of all the 
goods and services we produce each year, health care probably gives relatively good 
value for the money — at least as compared with SUVs, duct tape in some appUca- 
tions, and most of the available intoxicants. The purchase of health care, however, is 
really not comparable to any of the usual ways of spending money. One can always 
choose whether to buy a vacation home; buying a bone marrow transplant is rarely 
perceived to be optional when the occasion presents itself. Moreover, comparison 
shopping is difficult for experts and all but impossible for the typical consumer. 

The rising cost and increasing value of health care ha\'e proved to be irresistible 
forces colliding with seemingly immovable American political values and interest 
groups. The reality is that the only way to manage expenditures on health care is 
through some form of shared financing and collective decision making. Treating 
health care purely as a problem for the market would soon look like murder. But 
the prospect of a comprehensive solution requiring collective action and shared 
sacrifice seems ever more remote in a pohtical climate m which lower taxes and 
less government have emerged as the most fundamental values. 

1 would predict that physicians, however they vote, are going to find themselves 
in an increasingly uncomfortable position, seeming to control — or at least to influ 
ence in an important way — the quality and allocation of health care while in reali 
ty having a negligible influence on one of the most critical variables affecting their 
patients' health and prospects for recovery: the circulation of money through the 
health care system. 


&M[ (Aa 


William Ira Bennett '68 


Paula Brewer Byron 


Beverly Ballaro, PhD 


Susan Cassidy 


Elissa Ely '88 


Judy Ann Bigby '78 
Rafael Campo '92 

Elissa Ely '88 

Atul Gawande '94 

Robert M. Goldwyn '56 

Petri Klass '86 

\'ictoria McEvoy '75 

James J. O'Connell '82 

Nancy E. Oriol '79 

Eleanor Shore '55 


Laura McFadden 


Mitchell T. Rabkin '55, president 

E\'e J. Higginbotham '79, president-elect 1 

Joseph K. Hurd.Jr. '64, president elect 2 

Paula A. Johnson '85, vice president 

Phyllis 1. Gardner '76, secretary 

Cecil H. Coggins '58, treasurer 


Nancy C. Andrews '87 

Rafael Campo '92 
Donnella S. Green '99 
Barbara J. McNeil '66 
Laurence J. Ronan '87 
Mark L. Rosenberg '72 

Kenneth L Shine '61 

Francis C. Wood, Jr. '54 

Kathryn A. ZufaU-Larson '75 


Daniel D. Federman '53 


Nora N. Nercessian, PhD 


Joseph K. Hurd '64 

The Han/ard Medical Alumni Bulletin is 
published quarterly at 25 Shattuck Street, 
Boston. M.A 02115 < by tiie Harv,ird 
Medical .•Mumni Association- 
Phone: (617) 384 8900 • Fa.x: (617) 384 8901 
Email: bullctinffPhms. 
Third class postage paid at Boston. 
Massachusetts. Postmaster, send lorm 3579 
CO 25 Shattuck Street. Boston, M.A 02115 
ISSN 0191 7757 • Printed in the U.S.A. 




Wave of the Wand 

The Autumn 2002 issue of the Bulletin 
perpetuates the confusion between the 
symbols for communication and medi 
cine. On page 22, in connection with the 
article "Doctoring Evil," is pictured a 
fanciful rendition of the caduceus, the 
winged wand of Hermes (Mercury), 
messenger of the gods. This is the icon of 
commerce and communication. 

Obviously a symbol of the medical 
profession is intended. That would be a 
stout staff of Aesculapius, legendary 
healer. A large serpent entwines his 
staff, since in ancient Greece snakes 
were thought to play a role in healing. 

It is true that countless clinics and 
medical publications are adorned with 
Hermes's wand. And, as Dan Federman 
'53 emphasizes, communication with 
our patients is essential. Nevertheless, 
let us keep our icons straight. 


Editor's note: Alas, we should ha\'e held 
the image for this issue, which focuses 
on the intersection of medicine and 

On the House 

W'e bought our house in 1972, and along 
with other pleasures of living here has 
been the Bulletin. It has been sent to 
Dr. Kurt Toma all this time, as well as 
to the previous owners who were not 
Dr. Toma and his wife. Since we are sell- 
ing the house in the fall, you should can- 
cel Dr. Toma's subscription. 

We had a wall clock that was ill and 
we sent it to a clockmaker for repairs. 
When he returned to hang the clock, his 
father, a retired clockmaker, came along. 
Well, the father knew the house, as he 
had been here decades before to repair 
Dr. Toma's clock. He told us that 
Dr. Toma, a dentist, was the only hon 
orary member of the medical school 
alumni association — small world. 



Five members of the famous Class of 1937 
made the obituary pages of last autumn's 
issue of the Bulletin! As this list gets longer 
and our little red class report gets smaller, 
I wonder how long it will take to achieve 
oblivion. In December, it will be ten years 
since Lewis Thomas '37 died, and I was 
glad to read in the Bulletin that he and his 
poem "Allen Street" — inspired by our Sec- 
ond \'ear Show and published in the 1937 
Aeseulapiad — are still remembered. As 
many of you may know, Massachusetts 
General Hospital used its back door — 
which opened out onto Allen Street — to 
discharge patients headed for the morgue. 



CANTO I; Prelude 

Oh Beacon Street is wide and neat, and open to the sky — 
Commonwealth exudes good health, and never knows a sigh — 
Scollay Square, that lecher's snare, is noisy hut alive — 
While sin and domcsticitv are blended on Park Drive — 
And he who toils on Boylston Street will have another day 
To pay his lease and live in peace, along the Riverway — 
A thoroughfare without a care is Cambridge Avenue, 
Where ladies fair let down their hair for passersby to view — 
Some things are done on Huntington, no sailor would deny 
Which can't be done on battleships, no matter how wu trv — 
Oh, mam, many roads there are, that leap into the mind, 
(Like Sumner Tunnel, that monstrous funnel, impossible to find!) 
And all arc strange to ponder on, and beautiful to know. 
And all arc filled with living folk, who cat and breathe and grow. 


But let us speak of Allen Street — that strangest, darkest turn. 

Which squats behind a hospital, mysterious and stern. 

It lies within a silent place, with open arms it waits 

For patients who aren't leaving through the customary gates. 

It concentrates on end-results, and caters to the guest 

Who's battled long with his disease, and come out second-best. 

(continued on next page) 




(continued from previous page) 

For in a wcU run hospital there's no such thing as death. 
There may be stoppage of the heart, and absence 

of the breath — 
Bur no one dies! No patient tries this disrespectful feat. 
He simply sighs, rolls up his eyes, and goes to Allen Street. 
Whatever be his ailment, — M'hateer his sickness be. 
From "Too, too, too much insulin," to "What's this in his peer' 
From '"Gastric growth," "One lung, (or both)," or "'Question 

of Cirrhosis" 
To "Fxodus undiagnosed," or "Generalized Necrosis," 
He hides his head and leaves his bed, and covered with a sheet. 
He rolls through doors, down corridors, and goes to 

Allen Street. 
And there he'll find a refuge kind, a quiet sanctuary. 
For Allen Street's that final treat — the local mortuary. 


Oh, where is Mr. Murphy with his diabetic ulcer 
His orange-red precipitate and coronary? 

Well, sir 

He's gone to Allen Street. 
And how is Mr. Gumbo with his touch of acid-fast. 
His positive Babinskis, and his dark luetic past? 
And what about that lady who was lying in Bed Three, 
Recently subjected to such skillful surgery? 
And where are all the patients with the paroxysmal wheezes? 
The tarry stools, ascitic pools, the livers like valises? 
The jaundiced eyes, the fevered cries, and other nice diseases? 
Go! Speak to them in soothing tones. We'll put them on 

their fectl 
We'll try some other method, some newer way to treat — 
We'll try colloidal manganese, a diathermy seat. 
And intravenous buttermilk is very hard to beat — 
We'll try a dye, a yellow dye, or different kinds of heat — 
But get them on their feet — 
We'll find some way to treat — 

Vm very sorry. Doctor but they've gone to Allen Street. 


Little Mr Gricco, lying on Ward E, 

Used to have a rectum, just like you or me — 

Used to have a sphincter ringed with little piles. 

Used to sit at morning stool, face bewreathed with smiles. 

Used to fold his Transcript, wait in happy hush 

For that minor ecstasy, the peristaltic rush... 

But in the night, far out of sight, within his rectal stroma. 

There grew a little nodule, a nasty carcinoma. 

Oh, what lacks Mr Gricco? — Why looks he incomplete? 

What is this aching, yawning void in Mr Gricco's seat? 

Who made this excavation? Who did this foulest deed? 

Who dug this pit in which would fit a small velocipede? 

What enterprising surgeon, with sterile spade and trowel. 

Has seen some fault and made assault on Mr Gricco's bowel? 

And what's this small repulsive hole, which whistles like 

a flute? 
Could this thing be colostomy — this shabby substitute? 
Where is this patient's other half! Where is this patimt's seat! 
Why Doctor, don't you recollect? It's gone to Allen Street. 

CANTO \': Footnote 

At certain times one sometimes finds a patient in his bed. 
Who limply lies with glassy eyes recedmg in his head. 
Who doesn't seem to breathe at all, who doesn't make 

a sound. 
Whose temperature is seen to fall, whose pulse cannot 

And one would say, without delay, that this is a condition 
Of general inactivity — a sort of inanition — 
A quiet stage, a final page, a dream within the making — 
A silence deep, an empty sleep without the fear of waking — 
But no one states, or intimates, that maybe he's expired. 
For anyone can plainly see that he is simply tired. 
It isn't wise to analyze, to seek an explanation. 
For this is just a new disease, of infinite duration. 
But if you look within the book, upon his progress sheet 
You'll find a sign within a line — "Discharged to 

Allen Street." 

The Bulletin welcomes letters to the editor Please send letters by mail (Harvard Medical .Alumni Bulletin, 2d Shattuck Street, Boston, 
Massachusetts 02115); fax (617-^84-8901): or email (bullctm^^ Letters may be edited for length or clarity 



X LJ I i iki Pj L 


My Big, Fat Distal Swelling 


^%^m this year's Second Year 
^^^fl Show, "My Big, Fat Distal 
MjyH Swelhng," the Class of 2005 
explored what would happen if Nancy 
Oriol 79, associate dean for student 
affairs, were to gamble away the HMS 
cndowToent during an e\'ening of dancing 
and drinking. The day after tliis disastrous 
night on the town, as Oriol nurses a hang 
over. Dean Joseph Martin assembles the 
facult\' to inform them that the School's 
pockets are "emptier than a New Pathway 
classroom in April." Dean Martin has a 
plan: In addition to requiring all faculty 
members to donate an organ from their 
owTi bodies that corresponds to the disci 
phncs they teach (a request roundly 
refused by the cardiologists), Martin 
announces a competition; Because 
the School has only enough 
money to fund one depart- 
ment, the one that 
attracts the most 
students will be — ^ 

the sole survivor. 

Thus begins a "'- — ' 
whirlwind tour of 
HMS departments, with each 
strugghng to attract students in 
its own way. In the anatomy class 
room, professors sing the praises 
of the pass/fail option. Students 
favoring pathology face off 
against fans of endocrinology- 
clad in rubber boots, T-shirts, 
and bandanas, they stomp and 
clap rhythmically while shout 
ing back and forth, "Patho!" 
"Endo!" Immunology, cardiolo 
gy, and neurology students 
engage in a dance competition, 
featuring hip hop, traditional 
Indian dance, and swing num 
bers. And a group of male pro 
fessors form a boy band, 
"NSITU, while their female 
counterparts hit the stage as 
the Splice Girls. 

STEPPING OUT: From sprightly swing dancers to o coy oncJ 
pampered Material Girl, second year students pulled out all 
the stops to celebrate student life at Harvard Medical School. 

But the villain of 
the play, pharmacology pro 
fessor David Golan, has his 
own e\'il designs. Clad in a 
long black cape, he serves 
students pizza spiked with 
a drug that transforms 
them into zombies who 
love only pharmacology. 
E\en Golan isn't prepared 
for the results, though. The 
zombies take things too 
far — when quizzed on the 
uses of new drugs, they reply 
in deadened unison: "Pack- 
age the drug and charge as 
much as possible so we can 
all drive Bentleys." Horri- 
fied, Golan regrets his 

It's left to the one stu- 
dent who didn't eat the 
spiked pizza to find 

the antidote and bring the students 
back to life, with the help of a tutorial 
group. While the fearless leader of the 
tutorial is anything but (to the tune of 
"Maria" from The Sound of Music, she 
sings, "Why did I think I'd want to 
teach New Pathway? / Why did I think 
they'd ever want to learn?"), the stu- 
dents eventually develop the antidote, 
which has the unexpected side effect of 
curing male pattern baldness. With the 
money they make from selling the bald 
ness cure, the students are able to re- 
endow the school and leave the audi- 
ence with a happy ending. 

"I'm grateful to have been part of the 
Second Year Show with a group of peo ■ 
pie who, thanks to the show, have 
become lifelong friends," says producer 
Alexandra Casillas '05. "Being part of 
this show was one of the most reward- 
ing and memorable experiences of my 
medical school career." ■ 



The Future of Biotech Is Now 


hands on experience, but 
the term falls short when 
applied to Hugh Herr's 
demonstration of the prosthetic Otto 
Bock C Leg at a March symposium held 
by the Harvard-MIT Division of Health 
Sciences and Technology (HST). Judg- 
ing by the participants' faces as Herr, 
who lost both legs below the knee in a 
mountain climbing accident, strode 
around in the prosthesis that he and col- 
leagues invented, the workshop 
was both inspiring and stirring. 

One of the lessons that 
emerged from the symposium, 
"Experiencing the Frontiers of 
Biomedical Technology," is that 
HST is driven by a passion to 
help patients and that its work 
is central to their needs. Giving 
people a feel for its mission was 
part of the more general sym- 
posium goal of helping people 
understand how biotechnolog- 
ical advances actually occur. 

"There is a method, a para- 
digm that cannot be taught in a 
classroom or read in a book — it 
needs to be taught by doing," 
says Elazar Edelman '83, HMS 
associate professor of medicine 
at MIT and Brigham and 
Women's Hospital. "You cannot 
give people an appreciation for 
technology without doing tech- 
nology." Working on the model 
of the high school physics class, 
Edelman had the idea to launch 
a series of symposia in which 
people could first see how sci- 
entists approach biomedical 
problems, and then try it for 
themselves. The first sympo- 
sium was held last year. 

This year's workshop by 
Herr, HMS instructor in physi- 
cal medicine and rehabilitation 
at MIT, was part of a larger ses 

sion on "The Human Hybrid; Human- 
Machine Systems." Symposium atten- 
dees, who included venture capitalists, 
chief executive officers, lawyers, and 
graduate students, also had the oppor- 
tunity to attend sessions on drug deliv- 
ery systems, tissue engineering, hybrid 
biological microdevices, and informat- 
ics — topics that, according to Edelman, 
are "on the tips of people's tongues." 

What made Herr's leg demonstra- 
tion even more powerful was the recog- 

PRACTICAL MAGIC: "If we can apply greater energy flow 
and control it intelligently, the physically disabled person 
will really benefit," says Hugh Herr (right). Here he 
demonstrates the Otto Bock C-Leg at the Health Sciences 
and Technology symposium. 

nition, driven home earlier in the ses- 
sion by Steve Massaquoi '83, HMS 
instructor in neurology at Massachu- 
setts General Hospital, that lifelike 
mechanical devices begin as two- 
dimensional conceptual models. Mas- 
saquoi, whose own interest is in neuro- 
muscular prosthetic devices — artificial 
cochleas, retinas, and vestibular sys- 
tems, as well as brain stimulation for 
people with movement disorders — had 
students work on a simple computer 
model to understand how the 
brain controls their own arm 

Herr, who worked on the 
Otto Bock C-Leg, particularly 
the knee joint, for five years, 
also began with simpler mod- 
els and worked his way up to 
robots. "Making robots work 
sometimes shows us how we 
work," he said. "If we can build 
a robotic leg, we might build a 
prosthetic leg." The knee owes 
its lifelike motion to micro- 
processors that monitor and 
anticipate the user's actual 
movements. But it is a passive 
device. Herr hopes eventually 
to power the knee not with 
mechanical motors but instead 
with muscle. He has already 
developed a tiny fishlike robot 
that swims by means of 
impulses generated by an 
attached slice of laboratory- 
grown muscle. 

"One can imagine a future in 
which artificial appendages may 
be hybrid or cyborg — though I 
hate to use that word — de\ices," 
Herr says. "This may sound Kke 
science fiction, but everything 
is here today to do what I am 
describing." ■ 

Misifl Landau is the senior science 
writer at Focus. 


Retooling the School 


named the new dean for med- 
ical education at HMS. Cox 
most recently ser\'ed as asso- 
ciate dean for clinical education at the 
University of Pennsylvania School of 
Medicine. In his position there, he was a 
key advocate and participant in a major 
curriculum reform effort that closely par 
allcls the ongoing efforts at HMS. 

"A commitment to public, as well as 
individual, health must become the very 
core of medical professionalism," Cox 
says, "Harvard has a large and distin- 
guished faculty, which has recently 
rededicated itself to exploring new ways 
of educating physicians in the twenty- 
first century. I'm delighted to be return- 
ing as dean for medical education at a 
time of creati\'e tumult." 

"I am extremely pleased that Malcolm 
Cox is joining Har\'ard Medical School 
as our new dean for medical education," 
says Joseph Martin, dean of HMS. "His 
dedication to excellence in teaching and 
his experience in the development and 
impro\'ement of the medical school cur- 
riculum make him an ideal choice for 
this position. With his administrative 
experience as chief of the medical ser\'ice 
at the Philadelphia VA Medical Center 
and, more recently, in the Uni\'ersity of 
Pennsylvania Dean's Office, he will bring 
new and needed leadership that will be 
invaluable in planning our new initiati\-es 
in medical education." 

oversee the ongoing process of curriculum 
reform at HMS. 

Cox completed his postgraduate train 
ing in internal medicine and nephrology 
at the Uni\-ersity of Pennsylvania, where 
he had spent most of his professional 
career and where he had been a professor 
of medicine since I99I. His scholarly 
interests include kidney diseases, medical 
education, and health pohcy. Cox has lec- 
tured extensively on community-based 
primary care education as well as the 
content, governance, and financing of 
medical education. He has received 
numerous honors and teaching awards 
at the University of Pennsylvania. ■ 



U.S. News and World Report has 
rated HMS the top research-intensive 
medical school in the nation, accord- 
ing to its recently released 2004 rank- 
ing of graduate schools. The School 
tied for 17th among primary care- 
intensive medical schools. 

Schools also were ranked by med- 
ical specialties. As it did last year, 
HMS ranked number one for internal 
medicine, pediatrics, and women's 
health. It captured the number two 
spot in drug and alcohol abuse, the 
number three spot in AIDS, and the 
fifth spot in geriatrics. ■ 

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^% 'wfl Cox 70 from the Universi- 
^^^H ty of Pennsylvania to HMS 
lAA^HI as the new dean for med- 
ical education, the already intense 
focus on education revs up another 
notch. The New Pathway, a pioneering 
development two decades ago, is no 
longer new, and thus warrants recon- 
sideration and renewal. Surely basic 
science calls for thoughtful review of 
how its burgeoning nature and content 
are best taught and learned and how it 
relates to bedside and office practice, 
issues of public health, and the ethical 
dilemmas that are its offspring. 

As for clinical medicine, the frenet- 
ic delivery systems created by contem- 
porary payment modalities and stric- 
tures have led to a fragmentation of 
care, increasingly undermining the 
admonition of Francis Peabody '07 
that "the secret of the care of the 
patient is in caring for the patient." 

A patient may be seen in the office 
by his or her primary physician, where 
the workup of the complaint proceeds 
on an ambulatory basis until a diagno- 
sis is reached. Or the patient may be 
seen in the emergency unit by another 
set of clinicians and end up under the 
care of yet others — the hospitalists — 
for an all-too-brief inpatient stay. Stu- 
dents and house officers often have lit- 
tle opportunity to get to know such a 
patient, much less experience the 
spectrum of that patient's illness from 
the initial complaint and workup to 
the point of appropriate treatment 
and its unfolding consequences. 

This disjointed scenario also means 
less opportunity for students to expe- 
rience senior clinician teachers as role 
models, at least over time and in a vari 
ety of clinical circumstances and relat- 
ed interactions with patients and fam- 
ily members. Yet our responsibility is 
to teach not only the content of medi 
cine, but also how to be a physician, 
which is best taught by example. 

Daniel Lowenstein '83, who recent 
ly stepped down as dean for medical 

education, has commented that one 
major task ahead is to deal with the 
downside of the School's enjoying its 
primary affiliation with sc\cral major 
teaching hospitals. Becau,se clinical 
education is not coordinated centrally 
to the extent it should be, we lose the 
benefit of that diverse talent and 
thoughtfulness working fully together 
to make the whole greater than the 
sum of its parts. And within each hos- 
pital, little continuity exists between 
the overview of undergraduate teach- 
ing and that of the learning experience 
of house staff years. 

Fortunately, there is ferment here 
at HMS, a growing sen,se of the need 
to deal with these issues. The cre- 
ation of the Academy at HMS — 
which recognizes and creatively uses 
a special cadre of faculty devoted to 
teaching — and the work of the Carl J. 
Shapiro Institute for Education and 
Research — a joint venture of HMS, 
Beth Israel Deaconess Medical Cen- 
ter, and Mount Auburn Hospital — 
represent some of the results of that 
ferment. And under the leadership of 
Dr. Cox and Dean Joseph Martin, we 
can anticipate further progress in the 
months ahead. 

Last year around this time, we sent 
letters to alert alumni of the arrival of 
members of the Class of 2002 as house 
officers at their respective hospitals. 
Today, we simply ask you to keep an 
eye out for incoming residents from 
HMS '03 and, if you can, extend a wel- 
coming hand. The life of a resident is 
more stressful today than c\-er before, 
and a reassuring welcome will be 

greatly appreciated, i 

Mitchell T. Rahhin '55 is an Institute Scholar 
at the Carlj. Shapiro Institute for Education 
and Research at HMS and the Beth Israel 
Deaconess Medical Center, as well as chief 
executive officer emeritus of Beth Israel Hos- 
pital and CareGroup. 


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The Third Annual Mollis L. Albright '3 1 

Symposium will feature "The Scope of 

Vaccines in Our Present and Our Future: 

Challenges and Controversies" on October 

7, 2003, from 4:00 to 6:00 p.m. in the 

Daniel C. Tosteson Medical Education 

Center at Harvard Medical School. Joseph 

Martin, dean of HMS; Daniel Federman 

'53, senior dean for alumni relations and 

clinical teaching at HMS; and Dennis 
Kosper, executive dean for academic pro- 
grams at HMS, will be joining Gary Nobel 
'79, director of the Vaccine Research Center 
at the National Institutes of Health, and a 
panel of other experts. 

For more injormation, coniact Tcnlcy Albright 'tiJ 
at 617 247 S202 or t€nk\l003(!>''aolcom. 





On Patient Advocacy 



as the elderly woman was whisked off to the 
operating room. Ms. H. was a portly ZO-year- 
old with schizophrenia and mild mental retar 
dation. Talking to her casually, though, you 
wouldn't have guessed these diagnoses; she was lucid, \\'ith 
a subtle, at times sarcastic, sense of humor. 

Initiall)' admitted for chest pain, she ruled in for a myocar 
dial infarction, and a cardiac catheterization re\'Cctled three 
\essel disease. As members of the psychiatric consultation 
liaison ser\ice, we were asked to evaluate her for post-cath 
delirium. And delirious she was, at least for the first 24 hours. 
With the tincture of time, and a few cc's of haloperidol, she 
e\entually came around. The cardiothoracic surgeons decided 
she was a candidate for triple coronary artery bypass grafts 
and were aiming for surgery by week's end. Ms. H. was demur- 
ring, however, and we were asked to e\aluate her capacit)'. 

Nevertheless, I wondered whether a ZO-year-old woman, with 
an a\-erage remaining life expectancy of less than a decade, 
might ha\'e deserved the right to ha\'e her initial refusal taken 
more seriously. Did her diagnosis of schizophrenia and the 
label of mental retardation affect the willingness of the med 
ical estabhshment to give her refusal proper consideration? 

From conversations with others involved in the case, I think 
the answer, unfortunately, is yes. The fragmentation of med 
icine — and of patient care — among a growing number of spe 
cialists is ine\ itable, but its disad\'antages became clearer to 
me during this experience: critical medical decisions are 
increasingly being put in the hands of people with less and less 
fainiliarity with the patients themseh'cs. Ms. H. had no family 
to speak for her, no friends to support her decision against 
surgery. It was her opinion against those of the surgeons. 

Who knows what her course would have been had she not 
undergone the surgery? Regardless of her outcome, I feel a 

I would have done something. I feel responsible 
not for a "wrong" medical decision, but for not 
being a stronger advocate for my patient s wishes. 

My evaluation agreed with that of the attending physician: 
Ms. H. possessed the capacity to make decisions about her 
care. She understood the reason for the surgery, its attendant 
risks, and the risks in\'ol\'ed in not proceeding. She ne\'erthe^ 
less refused the surgery. She was afraid, as anyone might be, at 
the thought of open-heart surgery. She agreed, though, to 
allow us to continue discussing it with her, as she was not 
completely closed to the idea. Apparently the dialogue did 
continue, as next I heard she had agreed to the surgery, but 
wanted to go home for a few days to take care of some mat- 
ters, including taping an upcoming performance of the musi- 
cal Hansel and Grctd. This stated priority cUsturbed the sur- 
geons, who beUeved that it revealed a lack of capacity. They 
feared she might not return if allowed to lea\'c the hospital. 
Given her capacity, though, she was not held against her will. 

A week later she reappeared for the surgery. Sadly, her post- 
op course was complicated. Sevent)' two hours after surgery, 
she was weaned off the \'entilator but remained comatose. Her 
fate was not yet sealed, but her prognosis was not good. 

People with experience far greater than my own had 
beUeved at the time that the surgery was the right decision. 

sense of responsibiUty. It was not the first time that I had 
failed to speak up or act on a patient's behalf when my 
instinct told me to — -either because of my position as a stu 
dent, or, as in this case, because I was a member of a consult 
team unim'oh'cd with the aspect of care in question. I'm not 
sure exactly what I could have done that might have made a 
difference, but had I Ustened to my intuition, I w^ould have 
done something. I feel responsible not for a "wrong" medical 
decision, but for not being a stronger ad\'ocate for my 
patient's wishes. Perhaps if I had, she would now be comfort 
ably ensconced in her La-Z-Boy watching Hamd and Grctd. 

I see two things more clearly now: The first is the effect of 
psychiatric diagnoses like schizophrenia and mental retarda 
tion on the attitudes and decisions of health care profession 
ols. The second is that we can — and sometimes should — 
advocate for certain aspects of a patient's care even when, as 
is increasingly the case in today's medical emironment, they 
lie outside our specific purview; if done with appropriate tact 
and hurrality, patients only stand to benefit. ■ 

Arid Wcissmann '04 is a student at Harvard Medical School. 




The Trojan Women 

A Pla\ b\ Euripides. Translated jrom the Greek into English and 
Adapted in Response to Aristophanes' and Aristotle s Criticism 
by Howard Rubenstein '57 (Granite Hills Press, 2002) 


compound, there is not one lab reference, urinal- 
ysis, or frankly medical thought in this small 
book. And although the translator is a retired 
internist, he takes his topic far from medicine 
(but not all that far from general human health). "Perhaps," 
Howard Rubenstein '57 writes in his introduction, "if a theater 
company in every major city of the world were to produce The 
Trojan Women at least once a year, we might be closer to estab- 
hshing world peace." Mankind saved: not through vaccina- 
tion, but through art. Thoughts like this must be attended. 

Put down your JAMA, your hlcw England purnal of Medicine, 
your office copy of Entertainment Weekly. Sign the beeper out. 
Find a chair that sags. Remember years ago, before the era of 
CMEs, when you read for passion? Remember noble strug- 
gles and enmity, the grave absolutism of characters who 
knew themselves to be right when we feared they were 
wrong, and sorrows beyond sorrow? You don't? 

Read The Trojan Women. The play was first performed 
in 415 B.C. as part of an Athens drama competition. It 
hasn't disappeared since then; it is we who have left it 
behind, maybe because it is easy to read but difficult 
to absorb. These deep Grecian griefs and losses 
need to sink slowly through to the bones, 
while in modern times we often fly 
efficiently over emotion altogether. 

The plot is simple and catastrophic. It 
is a day or so after the end of the Trojan 
War (remember? ten years of brutal war 
to reclaim the faithless Helen?). Trojan 
women have been herded into a prisoner- 
of-war camp. Each will be given to a dif- 
ferent Greek leader — a bit of war booty — 
and borne off to Greece. Their husbands 
and sons are dead. They have been torn 
from their families. Now they sit and wait 
to be torn from their country. 

The ministering presence who waits with ' 
them is Hecuba. A week earher, she had been 
Queen of Troy. The women turn to her now 
because, even in chaos, social order perseveres 
But she is preoccupied. She, too, has lost all the 
corners of her kingdom. Her husband the king 
and her sons have been killed. One of her 
daughters is being murdered offstage as the 

play opens. Her grandson will be thrown off a tower before 
the first act ends. Her mad child will be torn from her and 
given to Agamemnon, the Greek commander. Still, the 
women turn to her. Hers are the eyes that watch history. "In 
the end, everything came to nothing. / And I witnessed it all." 
I read the play late at night, nursing a cold and fuU of xiral 
annoyance. My own family was sleeping upstairs. The cats 
wandered by, intrigued by the possibiht)' of company, then 
stretched and slept where they fell. Life is always good to them. 
I read lightly at first, skimming, as if the book were an 
abstract. By the end of Act I, though, the losses were so 
staggering, the heroism so acute, the die cast so bloodily, it 
was physically hard to bear. I thought: I can't finish this. 
These kinds of emotions are aerobic; they tax the heart; 
they need to be practiced. 

To distract myself, I picked up an old mythology refer- 
ence — lo, a handy doorstop all these years since college. I 
looked up Helen and Paris, then mad Cassandra and her 
fate, then the Trojan War itself, and that devious, irre- 
sistible Horse. Next thing I knew, I was reading a Tennyson 
poem about Iphigenia's sacrifice and looking at photos of 
ancient sculptures of Hector. Doors swung backward 
onto other doors filled with adjunct forms of art. I 
understood why an internist would devote his days 
to translating Greek plays — because thought, feeling, 
history, and content are a salvation from the arid 
forms of life that busy us today. 

In the play, of course, there was no sah'ation. The 
promised occurs without reprieve. The Trojan Women 
are borne, bodily apart but spiritually assembled, as 
Hecuba says, "forward into the new day of slavery." 
Yet they are also born, e-less, into meaning. "If 
God was not tormenting us / and torturing us / 
and dashing us to the ground," Hecuba muses, 
"no one would e\'er hear of us. / We would 
remain unsung fore\'er / instead of giving ever- 
lasting themes / in poetry and music / to future 

This, I think, is the point — of the play, and 
also of a physician who has taken the trouble to 
translate it after decades of reviewing lab values. 
We li\'e to be mo\'ed: by one another, by loss and 
heroism, by characters who say, in a thousand dif- 
ferent circumstances and through a thousand dif- 
ferent forms of expression, I can't go on, but I do. 
Their lix-es sax'c ours. Find what you care pas- 
sionately for, and use it to rescue mankind. Wit 
ness it in everlasting marmer. Sing about it. 
Dance it up. At the very least, put down your 
PalmPUot, please, and read. ■ 

Elissa El\ 'SS is a lecturer on psychiatry at HA IS. 








Ronald A. Heifetz 
Marty Linsky 


Maverick Among the Moguls 

The Adventurous Career of a Pioneer 
Cardiac Surgeon, by Benson B. Roc '43A 
(Creative Arts Book Company. 2002} 

Not originally intending to become a 
physician, Roe explains how he "backed 
into" medicine and took on a pioneering 
role in the early devekipment of cardiac 
surgery. His memoir offers insight into 
his clinical work, his contributions to 
an artificial heart project, and his efforts 
to tackle controversial issues in the 
country's surgical politics. 

Drama and Discovery 

The Storx of Histoplasmosis, by Thomas 
M. Daniel "55 and Gerald L. Baum 
(Greenwood Press, 2002) 

Basing their account on original and 
previously unreported source material, 
the authors tells the story of the fungal 
disease histoplasmosis, discovered in 
Panama in 1905. They trace the develop- 
ment of knowledge about the disease's 
etiology, pathogenesis, epidemiology, 
diagnostic challenges, clinical manifes 
tations, and treatment. 

Leadership on the Line 

Staying Alive Through the Dangers of 
Leading, by Ronald A. Heifetz '77 
and Nlarty Linsky 
(Harvard Business School Press. 2002) 

cultivate. The book also answers two key 
questions; How do one's actions as a 
leader cause resistance, and how does one 
effectively deal with that resistance? The 
authors examine the personal and proles 
sional dangers of leadership, and suggest 
ways to manage personal \'ulnerabihties 
and care for oneself while leading others. 

The Memory Cure 

How to Protect Your Brain Against Memory 
Loss and Alzheimer's Disease, by Majid 
Fotuhi '97 (McGraw-Hill, 2003) 

This "personal survival book" discusses 
qualities that leaders will find useful to 

The author summarizes the latest scien- 
tific studies in the field of memory 
research, explains the basics of the brain, 
and identifies the key features that distin 
guish Alzheimer's disease from the nor 
mal forgetfulness that comes with aging. 
He debunks myths about Alzheimer's 
and aging, and offers a ten-step memory 
protection plan to help minimize and 
delay the early onset of memory loss or 
Alzheimer's disease. 

Setting Limits Fairly 

Can We Learn to Share Medical Resources^ by 
Norman Daniels and James E. Sabin '64 
(Oxford University Press, 2002) 

The authors tackle the lack of consensus 
on principles for allocating health care 
resources fairly. They suggest four condi- 
tions under which it is ethically accept 
able for health care institutions to set 
limits on care, collectively termed 
"accountability for reasonableness"; pub- 
licity, relevance, appeals, and regulation. 

The authors then consider these condi- 
tions in a variety of health care contexts, 
including insurance coverage for new 
technologies, pharmacy benefit manage- 
ment, and physician incentives. 

The Eden Express 

A Memoir of Insanity, by Mark Vonnegut '79 
(Seven Stones Press, 2002) 

In 1971, Mark Vonnegut was committed 
to a psychiatric hospital to be treated 
for schizophrenia. The book is an 
account of his descent into mental ill- 
ness and his eventual emergence to 
become a practicing physician at Mass- 
achusetts General Hospital. Twenty- 
five years after its first publication, this 
memoir contains a new foreword by the 
author's father, writer Kurt Vonnegut, 
and a new preface by the author. 

Mind Over Fatter 

A Seven Step Mind/ Body Program for 
Permanent Fitness and Weight Control. 
by George R. Smith, Jr. '53 
(Rudedge Books, 2002) 

Of the seven steps in this slim, simple 
volume, only two are devoted solely to 
food and exercise. The other five focus 
on strategies for developing a clear 
vision of one's desired weight and 
lifestyle and for maintaining that focus. 
The author includes a detailed account 
of his own daily program and a series of 
progress logs designed to help readers 
follow the recommendations for achiev- 
ing weight control. 


R K N C H M A R K S 


Pressure Cooker: Protein Implicated in Preeclampsia 

by hypertension, edema, and protein in the urine, afflicts 
5 to 8 percent of pregnant women and is the leading cause 
of maternal death worldwide. Because it often compels premature 
delivery to save the mother, it is also a major cause of infant mortal- 
ity in developing countries. ^ The cause of preeclampsia has 

remained mysterious, and it has even 
been dubbed "the disease of theories." 
Now, researchers at HMS and Beth Israel 
Deaconess Medical Center (BID) have 
made a major ad\'ance by identifying a 
protein that may lead to the development 
of preeclampsia by blocking the acti\at)' 
of t\A'o angiogenic growth factors, vascu- 
lar endothelial growth factor (\'EGF) 
and placental growth factor (PlGF). The 
disco\'ery sheds light on the etiology of 
the disease at the molecular level, points 
toward further research on its ultimate 
causes, and suggests potential early diag- 
nosis and treatment strategies. 

"Currently, there is no treatment for 
this condition," also known as toxemia of 
pregnancy, says S. Ananth Karumanchi, 
HMS assistant professor of medicine at 
BID and senior author of the report in the 
March 3 is.sue of the Journal of Clinical Invcs 
tigation. "The only management we can 

offer patients is to deU\'er the baby and the 
placenta." Preeclampsia typically de\'el- 
ops after the 20th week of pregnancy and 
can rapidly progress to full'blo\\'n 
eclampsia with kidney failure, seizures, 
and other life-threatening comphcations. 

Co-author Franklin Epstein, the 
Wilham Applebaum Professor of Medi- 
cine at HMS and BID, adds that although 
typically thought of as an obstetric prob- 
lem, "Preeclampsia is also the world's 
most common renal disease — and too Ut- 
tle attention has been paid to this fact." 

A ncphrologist, Karumanchi's interest 
in preeclampsia comes from the obser\'a- 
tion that the glomerulus — the kidney's 
filtration apparatus — is pathologically 
affected in this disease by glomerular cap- 
illary endothehosis, in which endothelial 
cells become swollen and block the capil- 
laries, M'hich is behe\'ed to cause protein 
leakage into the urine. 

When a pregnancy proceeds normal- 
ly, the network of blood vessels to the 
placenta is remodeled to supply increas- 
ing oxygen and nutrients to the fetus. 
But in preeclampsia, the placental blood 
supply is instead reduced. Scientists 
have long speculated that this placental 
ischemia leads the placenta to release 
something into the maternal circulation, 
triggering the harmful events in the 
mother's kidney, liver, blood, and ner- 
vous system. 

To identify this unknown factor, 
Karumanchi and colleagues took placen- 
tal tissue from healthy and preeclamptic 
women and used microarray gene- 
expression profiling to see which genes 
were up- or downregulated in pre- 
eclamptic patients. Finding many differ- 
ences in gene expression, they focused on 
upregulated genes that encoded secreted 
proteins. One of these turned out to be 
soluble fms-like tsTosine kinase I (sFltl), 
a \'EGF receptor that blocks the growth 
factor's acti\ity. VEGF is an important 
angiogenic factor both in health and dis- 
ease. In cancer, excess \'EGF helps 
tumors grow ne\\' blood vessels, and 
\'EGF signaling inhibitors are in devel- 
opment as anticancer drugs. 

Karumanchi shared the microarray 
data with his co- author and mentor \'ikas 


of people wifh Alzheimer's disease also shows telltale patterns in 
the lenses of their eyes, a discovery that could lead to tests for 
diagnosing and monitoring the disease. The study, published in the 
April 1 2 issue of The Lancet, was led by investigators at Massachu- 
setts General hlospitol and HMS. 

"The formation of A-beta plaques in the brain and the devel- 
opment of cataracts in the lens are both examples of accumu- 
lated protein associated with age-related degenerative dam- 
age," says lead author Lee Goldstein, HMS assistant professor 
of psychiatry at MGH. "In addition, people with Down syn- 
drome, who develop Alzheimer's at an early age, ore also 
prone to early-onset cataracts. But as far as we know, no one 
hod investigated whether there might be any association 



Preeclampsia typically develops after the 20th week of 
pregnancy and can rapidly progress to full-blown eclampsia 
with kidney failure and other life-threatening complications. 

Sukhatme 79, chief of BID'S Renal Dhi- 
sion. Sukhatme knew that an antiA'EGF 
antibody being used in cancer therapy 
was causing hypertension and proteinuria 
in about 30 percent of patients. Checking 
with his oncolog)' colleagues, he found 
that cancer patients treated ^\'ith two 
unrelated \'EGF inhibitors were de\'elop' 
ing similar symptoms. 

"That was the 'aha moment," Sukhatme 
says. If three different drugs affecting 
VEGF .signaling produced hypertension 
and proteinuria, sFltl might do the same 
if it crossed from the placenta into the 
maternal circulation. 

Seeking e\adence that this is, in fact, 
what happens, first author Sharon May- 
nard, a renal fellow in Karumanchi's lab- 
oratory, found higher sFltl concentra 
tions in the blood of preeclamptic women 
than in healthy pregnant women, which 
dropped within 48 hours of birth. 
And Jaime Merchan, an oncologist in 
Sukhatme's laboratory, showed that 
blood from preeclamptic women blocked 
vessel growth in an in \1tro angiogenesis 
assay and that treatment with \"EGF or 
PlGF reversed this inhibition. 

To test the idea in xivo, the researchers 
then injected sFltl into pregnant rats. "The 

resulting data was exciting," says Karu- 
manchi. "The rats exposed to sFltl had dis 
tinct clinical and pathologiccil s)anptoms 
of preeclampsia — including the character- 
istic endotheliosis — demonstrating for the 
first time a clear cause-and-effect relation- 
ship between this protein and this dis- 
ease." It appears that sFltl "mops up" 
N'EGF and PlGF, he says, and the loss of 
growth factors damages the mother's 
small blood vessels, leading to the diverse 
symptoms of preeclampsia and eclampsia. 

"This research will now e\'oK'e in sev- 
eral different directions," Karumanchi 
says. "First, we need to understand why 
sFltl is upregulated in preeclampsia." 
Genetic, immunologic, and emironmen- 
tal factors will all need to be exainincd, 
he says, and maternal paternal antigenic 
incompatibihty may play a role. 

"Second, it will be interesting to see if 
measurement of blood sFltl, VEGF, and 
PlGF le\'els wiU allow us to de^'elop a test 
that can predict which patients will 
develop preeclampsia w^ell before the 
onset of symptoms," he adds. "Third, we 
have a rationale for using these growth 
factors, or other approaches that would 
block excess sFltl, to see if they might be 
useful in treating the disease." 

One potential treatment is suggested 
by one of cigarette smoking's few benefits: 
a reduced incidence of preeclampsia that 
may be mediated by lowering sFltl and 
increasing \'EGF production. This sug- 
gests that short term nicotine treatment 
could be used for se\'ere preeclampsia. 

The work also has implications 
for anti-angiogcnic cancer therapy, 
Sukhatme adds. Although patients on 
VEGF-signaling inhibitors must be 
watched for hypertension and protein- 
uria, "there may be a silver lining," he says, 
since these symptoms could ser\'e as sur- 
rogate markers for the drugs' efficacy. ■ 

Tom Reynolds is a writer in the HMS dearis office. 

between the pathology of Alzheimer's disease and age-related 
changes in the lens." 

The researchers used immunologic assays and mass spectrome- 
try to look for evidence of A-beta in lens tissue from nine autopsied 
Alzheimer's patients and eight controls. In specimens from both 
groups, they found the protein in concentrations similar to those 
found in aged brain tissue samples. They also found A-beta in sam- 
ples of aqueous humor taken from three non-Alzheimer's patients 
who were having cataracts removed. 

Most importantly, they found in Alzheimer's patients — but not 
controls — both cataracts and a distinctive pattern of cytoplasmic A- 
beta deposits in the outer, peripheral portion of the lenses. The lens 
does not clear protein deposits the way brain tissue does, and the 
researchers believe the protein deposits cause the cataracts. 

"One of the most exciting aspects of this finding is the fact 
that these deposits are associated with a type of cataract seen 
rarely in the general population," known as equatorial 
supranuclear cataracts, says Leo Chylack, Jr. '64, HMS pro- 
fessor of ophthalmology at Brigham and Women's Hospital. 
"These cataracts do not block vision and can only be seen 
when the pupil is dilated widely, so they previously would not 
have been detected in Alzheimer's patients. If the association 
of these deposits with Alzheimer's holds up in future studies, it 
would be very simple to develop a noninvasive test of disease 
progression." Chylack and Ashley Bush, HMS associate pro- 
fessor of psychiatry at MGH, are co-senior authors of the 
Lancet report. An intensive project to develop such a test is 
under way. ■ 













by Beverly Ballaro^ >> 


financial freedom to exercise it — have long been 
hallmarks of the medical profession in the United 
-.^ ..: .^ States. Perhaps no job outside of cowboy has better exem- 

^^^.K- plified the spirit of rugged individualism \'alued in Amer- 

ican culture. Certainly none has commanded as much 
PHOTOGRAPHS BY CHRISTOPHER HARTING prestige and respect in our society over generations. 



r^hu'i-.-^^^r . 


And yet much has changed in the years since 
Waylon Jennings and Willie Nelson crooned their 
paean to the notorious rootlessness of cov\'boys — 
and the comparative steadfastness of physicians: 
"Mamas, don't let your babies grow up to be cow- 
boys / Don't let 'em pick guitars or drive them old 
trucks / Let 'em be doctors and lawyers and such." 

Were Waylon and Willie dispensing career coun- 
seling today, they might be inclined to revise, as a 
growing number of clinicians are already doing, their 
assessment of the advisability of pursuing a medical 
career. Physicians training and practicing in the con- 
temporary marketplace operate in a world that bears 
scant resemblance to the one of professional autono- 
my enjoyed by physicians of earlier generations. 

Young doctors today are entering a medical land- 
scape substantially different from that of even a 
decade ago, according to the dean of Har\'ard Med- 
ical School, Joseph Martin. While the same spirit 
that inspired generations of physicians to pursue 
their profession may still motivate today's aspiring 
and practicing clinicians, these cUnicians must grap- 
ple with career limitations imposed, says Martin, by 
"managed care, uncertain salaries, and weakened 
hospitals and practice groups." 

Economic factors are clearly driving physician 
career decision making in unprecedented and 

often — from the perspective of medical school 
deans, medical students, patients, and many practi- 
tioners themselves — unwelcome ways. And the 
pressures on physician decision making directly 
correlate with levels of physicians' job satisfaction, 
according to a recent study pubHshed in the journal 
of the American Medical Association. 

Lead author Bruce Landon, assistant professor of 
health care policy and medicine at HMS, and his 
colleagues discovered that, more than income and 
finances, the degree of physician autonom) — specif- 
ically, the freedom to make cUnical decisions in the 
best interests of patients, to spend enough time with 
patients, and to maintain continuing relationships 
with them — was the key factor in determining pro- 
fessional happiness. 

"Physician career dissatisfaction most commonly 
stemmed from a perceived loss of autonomy," says 
Landon. "Some physicians expressed frustration at 
what they viewed as an inabihty to practice as they 
wanted and had been trained to practice." Yet Lan- 
don and his colleagues found that, with some key 
local market exceptions, the national le\'el of physi- 
cian career satisfaction has remained steady since the 
mid-1990s. This general level of professional content- 
ment reflects, the researchers suspect, reforms in 
managed care plan practices that had tended to limit 





by Nakela Cook 

When I arrived at HMS, 1 quickly realized that 
I had significantly underestimated the cost of 
financing my medical education on my own. 
I found myself always just a little behind each 
month, forced to borrow from the upcoming 
month's budget. I survived in that fashion for 
three years, but inevitably reached the point of 
depleted funds, growing credit card debt, and 
rent higher than I could afford. My money 
worries peaked at a time when medical school 
stress was also reaching its height. 

I decided to take a year off and work in 
the hopes of decreasing my debt. Even so, 
during four years at HMS, I ended up borrow- 
ing $150,000. Once principal and interest 
are repaid, the total cost of my medical edu- 
cation will be more than $350,000. 

In medical school, I hod originally been 
interested in a career in primary care. I 
wanted to tackle such issues as death from 

preventable or treatable illness, access to care 
among marginalized members of society, and 
differences in outcomes of diseases and treat- 
ments based on race, socioeconomic status, 
and gender. I struggled with how I would rec- 
oncile a career in the social aspects of medi- 
cine, traditionally accompanied by a lower 
salary, with my growing loan burden. 
Based on a change in my clinical 
interests, I applied for a fellowship in cardiol- 
ogy. I realized that this specialty would pro- 
vide me with the opportunity to pursue my 
research goals in health disparities within the 
field of cardiovascular outcomes and give me 
a salary that would allow me to repay my 
loans while maintaining a reasonable lifestyle. 
But consider the many students, some of 
whom I personally tried to recruit to HMS, 
who often find themselves weighing a full 
scholarship at a state institution against siz- 



.gi _.,^ i.«' 



able loan burdens to attend an institution like 
HMS. Many of these students are from under- 
represented groups. For those from less eco- 
nomically secure backgrounds, assuming a 
large financial obligation may not be accept- 
able, while others cannot fathom attending 
any medical school because of the huge cost. 

As a result of student debt, we are losing 
diversity at our top medical schools, where 
leaders in the field ore educated and 
groomed, not to mention diversity in medi- 
cine as a whole. If diversity is crushed, our 
work in underserved communities is compro- 
mised and our mission to bridge the gaps in 
health care becomes impossible. 

Nakela Cook '00, a senior resident in primary 
care/internal medicine at Massachusetts 
General Hospital, will begin a cardiology 
fellowship in 2004. 


-,«».^ ' *;.;jr5^ 

.wm^i^*"' *■ <^F^,<: :'•^.■:^^^LJ:'*^.'' 



from that of even a decade ago, according 

clinical autonomy. Such restrictions had been put 
into place in the late 1980s and early 1990s to keep 
costs dowTi but ultimately provoked a backlash on 
the part of patients and physicians aKke. 

Yet even as the overall measure of professional 
satisfaction in medicine has stabilized, an increas- 
ing number of physicians are speaking out about 
how the financial constraints imposed by the pre- 
sent health care system and the faltering economy 
are placing their autonomy in fresh jeopardy. 

What's an MD Really Worth? 

The cold, hard facts of medical education today 
involve a great deal of cold, hard cash. The HMS 
admissions office estimates the current cost of one 
year of study at the School, including tuition and 
fees of $32,708, to be in the neighborhood of 847,750. 
Multiply that by four years and today's Harvard- 
trained physicians are looking at an educational 
investment that will require a fairly hefty return to 
make it worthwhile — at least from a purely dollars- 
and cents perspective. 

"If someone is looking for a career that is intellec- 
tually rewarding and in which a person can stiU 
make a reasonably good li\'ing, medicine continues 
to stack up pretty well," says Landon. "But the 
return on investment in medicine is no longer near- 
ly as superior as it once was compared to other pro- 
fessions. I hear stories all the time now of young 
doctors practicing in the Boston area, for example, 
who cannot afford to buy homes. That used to be 
unheard of but is increasingly the case." 

Medical school debt is also increasingly worri- 
some to HMS administrators who are already seeing 
the fallout in student career decision making. In con- 
versation after conversation with recent graduates, 
Daniel Federman '53, senior dean for alumni rela- 
tions and clinicd teaching, has heard confirmation of 
the disturbing tendency for some students to shy 
away from personally rewarding and socially benefi- 
cial career choices in response to the burden of debt. 

Dean Joseph Martin has characterized the enor- 
mous debts accumulated by many students as "a 
staggering load for someone about to indenture 
him or herself to three to eight years of resident 
training" and has noted that the impact of debt is 


today are entering a medical world substantially different 
to the dean of Harvard Medical School, Joseph Martin. 

clearly making itself felt in students' choices of spe 
cialty career paths. Between 1998 and 2000, HMS 
graduates expecting to enter research fields 
declined from 15 to 9 percent, with increasing num 
bers — now nearly 10 percent — expecting not to 
practice medicine at all. 

The HMS administration has been scrambling 
for new ways to alleviate the debt burden on stu 
dents, given that currently only 6 percent of 
endowed funds are earmarked for scholarships. In 
2002 Dean Martin announced the HMS Scholar- 
ship Campaign, whose goal is to raise $35 million 
over three years to replace some loan money with 
increased grant support. 

In the meantime, more and more HMS gradu- 
ates are feehng the financial crunch. One alumnus, 
who prefers to remain anonymous — because, as he 
explains, "people don't like to hear doctors, espe- 
cially surgeons, whine about finances" — is saddled 
with monthly loan payments of nearly S2,000 for 
many years to come. He embarked on his career 
owing the School $50,000 and the federal govern 
ment an additional SIOO.OOO, and is now ha\'ing 
second thoughts about the wisdom of choosing his 
subspecialty, which is not known for especially 
high rates of compensation. He and his wife and 
would like to start a family but have put their 
plans to have children on indefinite hold, as they 
struggle to figure out a way to refinance his debt 
burden in a way that will allow them to maintain 
their modest lifestyle and, at the same time, plan 
responsibly for insurance, child care, college, and 
other family costs. 

A Distinct Liability 

"Frankly, I don't know who's going to be delivering 
babies anymore," worries Charles Welch, an 
instructor in psychiatry at HMS and past presi 
dent of the Massachusetts Medical Society, refer- 
ring to the impact of the skyrocketing cost of mal- 
practice insurance on obstetricians. According to 
Welch, S600 of the total cost of every baby deliv- 
ered in Massachusetts today is earmarked for mal- 
practice insurance. When the largest malpractice 
insurer in the commonwealth raises doctors' pre- 
miums 20 percent as it is scheduled to do this sum- 

mer, the average Massachusetts obstetrician's 
insurance costs will jump from $84,000 to more 
than $100,000 annually. 

Obstetrics isn't the only iicld hard hit, says 
Welch. The high cost of malpractice premiums is 
forcing some physicians to drop out of practicing 
other high-risk specialties such as neurosurgery, 
and the strong trend among medical students, he 
adds, is to pursue low-risk, high income special- 
ties. And the problem isn't restricted to Massachu- 
setts. Across the nation over the past year insurers 
have been hiking premiums as much as 20 percent, 
leading to a high profile surgeons' strike in West 
Virginia and a job action in Pennsylvania. The rate 
increases have also sparked an acrimonious politi- 
cal debate as to the root cause of the problem. 

Regardless of its origins — whether it stems from 
egregious jury awards won by overly aggressive trial 
lawyers, as some factions contend, or from excessive 
biUing of doctors by a malpractice insurance indus- 
try struggling to compensate for losses in tough eco- 
nomic times, as others argue — one fact everyone can 
agree upon is that more and more physicians are 
beginning to tailor career decisions on the basis of 
tfiis new economic reaUty. 

One such physician is James Wang, a Springfield, 
Massachusetts obstetrician-gynecologist who, after 
months of agonizing, stopped delivering babies. 
Wang made his decision when his original insur- 
ance provider, eager to get out of business in Mass- 
achusetts, terminated its contract with him early. 
Scrambling to find another carrier quickly, Wang 
was offered rates 100 to 115 percent higher than 
what he had been paying. 

Making the decision to stop delivering babies 
was particularly wrenching for Wang, who was 
raised by two physician parents; "I used to accom- 
pany my mother and father on their rounds as old- 
fashioned country doctors. I grew up absorbing 
the idea of medicine as a wonderful, noble profes' 
sion." Wang never imagined, he says, that one day 
he'd be forced to give up part of his calling because 
of insurance costs. "My dream was to be able to 
deliver the babies of babies 1 had delivered," he 
says, adding that he still hopes to find a way to 
serve that second generation but isn't sure if it 
will be possible. 




don't know who's going 
an instructor in psychiatry at HMS and past 

"Rising malpractice costs " Wang says, "are just 
the tip of the iceberg. Most people think in the realm 
of dollars and cents but they forget that physicians 
are human beings with lives, families, responsibili 
ties, needs, and wants. The level of stress on a daily 
basis in obstetrics is incredible. Yes, I chose this 
field, but in return for the long hours, missed family 
time, and tremendous job pressures, I hope to be 
able to make a reasonably good lix'ing. But there are 
so many impediments today. The malpractice crisis 
is the last straw for many physicians. I love what I do 
but, if I knew starting out in medicine what I know 
now, I'm not sure I would have chosen this path." 

For Wang, all options are on the table, including 
the possibility of relocating out of state. He is not 
alone. A recent survey of 7,565 Massachusetts 
physicians and other health care field professionals 
conducted by the Massachusetts Medical Society 
shows that, for the second consecutive year, a seri- 
ous shortage of physicians in key specialties is ere 
ating a recruiting crunch for hospitals. The results 
indicate that overall, 28 percent of doctors sur- 
veyed are considering a career change, with 40 per- 
cent in obstetrics and 56 percent in neurosurgery 
mulling new paths. 

"Obstetrics is such a wonderful field with so 
many rewards," Wang says, "but I would have to tell 
medical students considering the field today that, 
unfortunately, you can't follow your heart alone. It's 
wonderful if you love what you do, but if you can't 
make a Uving at it, how are you going to manage?" 

You Get What You Pay For 

Last year, when Harold Solomon, associate clinical 
professor of medicine at HMS, decided after 33 
years of practicing medicine to join a concierge 
medical organization, he heard mostly criticism 
from his colleagues in academic centers. But, 
according to Solomon, the concierge medicine con- 
cept does not deserve much of the controversy 
swirling around it, given the degree to which the 
notion of paying a premium price for premium ser- 
vice is inculcated into American culture. 

"One-size-fits-all would be terrific for medi- 
cine," Solomon says, "if reimbursements had not 
shrunk, or if costs for unnecessary documentation 

and malpractice premiums had shrunk in propor- 
tion to reimbursements." 

A concierge practice has allowed Solomon the 
freedom to practice in a way that had become impos- 
sible over time with the escalating financial pres- 
sures of modern medicine. "I was forced to look hard 
at the numbers," he says. "The average internist in the 
United States earns perhaps $120,000 per year. My 
overhead was S200,000, including office staff, billing 
costs, insurance, utilities, maihng costs, and depreci 
ation. The average reimbursement per \isit was S70. 
If I had only 2,700 patient \'isits per year, I would lose 
SII,000 annually. I did not start pa)ing myself until 
after the first 2,700 \isits. At 4,000 \isits, I generated 
$280,000, earning $80,000. Four thousand \isits take 
2,000 hours, which is 40 hours per week, 50 \\'eeks 
per year. And then there are letters to write, phone 
calls to return, hospital visits to make, and an office 
to run. I also try to teach, attend conferences, and 
read the medical literature. 

"I was taught to schedule routine visits every 30 
minutes," Solomon adds, "which I continued to do 
up through the last year of my previous job." But 
when the economic disadvantages of his tradition- 
al way of doing things became overwhelming, he 
tried to modernize. He stopped admitting patients, 
relying on a hospitalist instead. He shortened his 
visit intervals in an attempt to increase his produc- 
tivity. But doing so, he found, also shortened his 
temper and led to missed phone calls and delayed 
visits. "I realized," Solomon says, "that the quality 
of my work was my driving force. It's more impor 
tant to me to have satisfied patients than to be 
'productive' and 'efficient.'" 

So in 2002 Solomon closed his practice, which 
had served 1,250 patients, and offered them the pos 
sibHity of following him, for an annual fee of $1,500, 
to a new concierge practice he had joined. He grant 
ed "scholarships" to many patients to whom he had 
provided unique care or with whom he had strong, 
long-standing attachments. In addition to the annu- 
al fee, of which he recei\'es a portion, Solomon bills 
patients fee-for-service in the usual manner. The 
patients, he says, are assured access and quality of 
care, with a special emphasis on prevention. 

One could argue the fairness of this approach to 
delivering care, Solomon admits, but he is con- 



to be delivering babies anymore," worries Charles Welch, 
president of the Massachusetts Medical Society. 

vinced that, given the opportunity to seek out and 
pay more for services, many patients will decide 
that it serves their best interests to do so. Under 
the current system, he says, society's leaders can- 
not decide whether health care is a commodity or a 
service, a right or a privilege. 

To address this dilemma, Solomon has a propos- 
al: "Define incentives for quality work that both 
patients and doctors understand. Nationalize the 
health care system. Give everyone a Medicare card. 
Let the political process determine the floor, but 
allow the markets to determine the ceiling. Let 
physicians and hospitals charge premiums for pre- 
mium service. Deregulate copayments altogether." 

By building a floor for everyone but allowing the 
ceiling to float, Solomon argues, "we will all get 
some care, and those who w^ant and can afford more 
will have the right to purchase as much as they 
want. Employers could offer more benefits as an 
inducement for employment." And, he adds pointed- 
ly, "Doctors will choose careers knowing that they 
can earn a living and take pride in their work." 

Solomon now sees half the number of patients 
he saw during his last year at his previous job. "I 
make home visits," he says. "I'm on time again and I 
return calls promptly. I never turn off my beeper, 
unless I'm abroad. I take my own calls. My com- 
puter-based office and hospital patients' records 
are always available. .Although there has been a 
nationwide hue and cry about this style of medi- 
cine, both my morale and the quality of my practice 
have soared." 

Rules Rush In 

Although members of the physician community at 
HMS, as in the nation at large, have responded to 
the economics of today's medicine with a range of 
career decisions, they are nearly unanimous in the 
opinion that the present system is, in the long view, 
untenable. The enormous challenge of transform- 
ing the economic context in which medicine is 
practiced in this country is going to require, most 
seem to agree, an unprecedented combination of 
strong leadership and political wUl. 

Nothing short of a full-scale reinvention of the 
health care system — "the only major American 

industry not to have modernized in our life- 
time" — is in order, says Charles Welch, given what 
he sees as the incredibly wasteful inefficiencies 
that both harm the interests of patients and con- 
strain professional decisions for doctors. "Admin- 
istrative overhead currently soaks up 40 cents 
of every health care dollar," Welch laments. "We 
have created a system that requires an army of 
administrative specialists in the operations of 
both insurers and providers. Most of this activity 
adds nothing to the quality or effectiveness of care, 
and it drains hundreds of billions of dollars away 
from urgent clinical needs." 

Compounding the problem, Welch adds, are 
"antiquated systems of information and care dehv- 
ery; our infatuation with wildly expensive new 
drugs and de\ices, many of which are no better than 
old approaches that are a fraction of the cost; the use 
of lawsuits to compensate injured patients; and a 
gross underfunding of health care in general." 

For Bruce Landon, who has focused part of his own 
career on measuring the degree of satisfaction that 
physicians enjoy with their career choices, the broad 
picture of a fairly contented profession can be mis- 
leading. "Our study provided just one snapshot 
glimpse at a complex and e\'ol\ing situation," says 
Landon. "While it may be true that o\-erall levels of 
physician dissatisfaction do not seem to have 
increased dramatically, it's important to take stock of 
the local variations. It's also crucial to keep tracking 
the cumulative effects over years. A lot of httle events, 
which may seem like mere ripples when examined in 
isolation, can add up to a serious trend over time." 

For the administrators at HMS and other medical 
schools around the country, the question remains, as 
Bruce Landon frames it: "Are we attracting and will 
we continue to attract the best people to medicine? 
When bright young people have to choose between 
medicine and, say, law, will they pick medicine, 
given the educational debt burdens and hassles 
physicians face?" A nation whose well-being lies in 
the hands of the next generation of physicians can 
only hope for the kinds of reforms that pro\ide an 
affirmative answer. ■ 

Bcvaiv BaUaw is associate editor of the Harvard Medical 
Alumni Bulletin. 






\\ rational solution in American political life as the ongoing crisis 
f f in health care financing. Millions of Americans are uninsured, 
and health care costs continue to escalate. The ^iA\am asked several 
physicians and economists for their perspectives on the current state 

of health care in the United States. Included in the dis- 
cussion were Da\dd Blumenthal 74, director of both the 
Institute for Health Pohcy at Massachusetts General 
Hospital and the Harvard University Interfaculty Pro- 
gram on Health Systems Improvement, who also served 
as moderator; Stuart Altman, PhD, Sol C. Chaikin Pro- 
fessor of National Health PoHcy at The Heller School for 
Social Pohcy and Management at Brandeis University; 
Joseph Newhouse, PhD, director of the Harvard Division 
of Health Pohcy Research and Education; and Charles 
Welch, MD, past president of the Massachusetts 
Medical Society. Excerpts from their discussion follow. 


wa\'e a wand and arrange for universal 
co\'erage, what would you put in place? 

STUART ALTMAN: While polls show- 
that about 85 percent of Americans 
support pro\1ding health insurance for 
everyone, proposed solutions always 
break down o\'er who's going to pay — 
and who's going to run the new sys- 
tem. My preference would be to build 
on our current system. I would lower 
the eligibility age for Medicare and 
allow certain individuals — those who 
retire early or, for a variety of reasons, 
aren't working — to buy into it. And I 
would expand Medicaid to cover peo- 
ple just abo\'e the poverty line. 



JOSEPH NEWHOUSE: Achieving univer- 
sal coverage would require a consider- 
able element of compulsion. The unin 
sured will not \'oluntarily insure them 
selves unless they are hea\'ily subsidized 
to do so. This will require taxing the 
population; telling people, just as we 
inform car owners, that everyone 
be insured; or ordering employers to 
provide some kind of insurance. 

ALTMAN: I agree that there is simply no 
way to reach anything resembling uni 
versal coverage without a mandatory 
system. And it's going to require a much 
higher level of subsidy than that pro- 
posed by the current administration. 
You're not going to accomphsh uni\ersal 

coverage by handing low- income people 
,$3,000 and telling them, "Here — go buy 
insurance." People with annual incomes 
between .$15,000 and .$30,000 are not 
going to purchase insurance that costs 
$10,000 to $12,000 per family 

CHARLES WELCH: I'm curious as to 
what you think about a system in which 
federal taxation poHcies would pro\ide 
people with incentives to purchase 
insurance individually. 

NEWHOUSE: Employer pro\ided insur- 
ance has two major advantages: it is sub- 
stantially cheaper because you don't 
market as much to individuals, and, 
in general, employment groups are not 

formed for the purpose of getting health 
insurance. So, to a large degree, one 
a\'oids problems of adverse selection and 
the death spirals that can occur in indi 
vidual insurance. I think that one of the 
reasons for the enactment of Medicare 
was that the indi\idual insurance mar 
kct didn't work well for the elderly. 

WELCH: The idea of taking the employ- 
er out of the business of providing insur 
ance for employees and empowering all 
Americans, through refundable tax 
credits, to purchase insurance directly is 
a conser\'ative fa\'orite. 

ALTMAN: But for it to work over a long 
period of time, the government would 



V V J- X J. J — /-L< it's true that, in the short run, 
fee-for-service system, I find it hard to beUeve that 

have to be willing to continue to upgrade 
those tax credits to accommodate what 
has been — for the past 50 years at least — 
a continuous growth rate of health care 
spending, because patients want more 
and better. And physicians want to pro- 
vide the best care possible. 

I'm concerned that those tax credits 
would not keep pace with health care 
costs. At some point, consumers would 
hkely demand that the government regu- 
late the system, which would mean major 
restructuring and cuts, primarily in fees 
paid to hospitals and doctors. I suspect 
what may sound hberating for physicians 
would be only temporarily so. 

WELCH: Despite its risks, I thmk that 
the principal attraction of such a plan is 
that it would bring an infusion of cash 
into the system from the federal govern- 
ment that would move us closer to 
achieving universal coverage. 

ALTMAN: To accomplish this goal, you 
have three choices: You could go through 
individuals, thus breaking down the 
employer-based system; you could have 
the government run the whole system; or 
you could ha\'e the government heaxoly 
subsidize individuals through either 
Medicare or Medicaid while pro\iding 
support to small businesses to help them 
defray the cost of covering their employ- 
ees. All of these options would require a 
substantial infusion of money from the 

But if we dorit do anything, what wiU 
happen is that insurance companies wiU 
develop big deductibles and co-insur- 
ance. The thing that physicians fear the 
most will happen — patients wiU be com- 
ing to them with no coverage. And physi 
cians will return to the days of accepting 
chickens and pies as alternative forms of 
payment. It's not good for physicians, and 
it's definitely not good for patients. 

BLUMENTHAL What are your thoughts 
on a single -payer system, as opposed to a 
tax-credit approach and employment- 
based approach? 

NEWHOUSE: Part of the problem with 
the idea of a single -payer system is that 
it defines a slogan better than it does 
a policy. To me, the simplest way to 
achieve a single-payer system in this 
country would be to pronounce every- 
one eligible for Medicare, which does 
have a functioning payment system and 
does approximate a single payer for the 
elderly. But Medicare looks very differ- 
ent from what many advocates of the 
single- payer system have in mind, 
which is something that resembles the 
Canadian system. 

ALTMAN: Every other industrialized 
country has universal coverage, but 
many people don't realize that no two of 
those systems look alike. Canada does 
not have a national system, but a 
provincial one. The federal government 
subsidizes the care that the pro\'inces 
deliver by issuing block grants. Each 
province provides a basic set of services, 
similar to the way we do in Medicaid, 
but they are also free to provide more 
services if they can afford to do so. 

In Great Britain, tax revenues go to the 
central government, which creates a 
delivery system in which physicians may 
nominally be private, but are controlled 
by income from the government. 

A third model is Germany, in which all 
individuals are required to have health 
insurance and all employers are obhged to 
provide it. Individuals can obtain insur- 
ance through their employer, their union, 
the towTi they grew up in, or a variet}' of 
places. The premiums are shared 50/50, 
not 80/20 like we talk about here. 

The German Medical Society is given a 
fixed pool of money each year. The soci- 

ety fights with a cabal of insurance com- 
panies to decide how big that pool will 
be. But once the pool is established, it 
becomes the responsibUit}' of the societ}' 
to allocate that money to the physicians. 

NEWHOUSE: Most, if not all, of these uni- 
v'ersal co\'erage systems are not really sin- 
gle payer systems. Most European coun- 
tries ha\'e escape val\'es for the wealthy; in 
some countries, high earners are exempt- 
ed from the compulsory plan. In the UK, 
people in the upper income brackets 
can — and frequently do — buy insurance 
that allows them to jump the queues for 
elective surgery. No major country that I 
am aware of has a strictly single-payer, 
govermnent-run plan. 

BLUMENTHAL But, in both Britain and 
Canada, everyone has insurance paid for 
by tax revenues. 

ALTMAN: Most people who talk about 
uni\'ersal co\'erage in the United States 
are emisioning a plan that is substantial- 
ly better than Medicare. Actually, this is a 
real problem with discussing national 
health insurance, because whene\'er you 
propose mandating a particular plan, all 
groups related to health care immediateh' 
lobby hard to make sure that their ser- 
\ices are included. 

What started out as, if you w ill, a 
physician insurance system — if a physi 
cian didn't perform a ser\ice or wasn't 
part of it, you wouldn't get reimbursed — 
is now something different. Legitimate 
arguments are being made by psychiatric 
social workers, speech therapists, and 
other professionals who, for many people, 
are as important as physicians. But what 
happens is that they add more and more 
layers, so we wind up with a system that's 
much more expensi\'e and expansi\'e than 
Medicare. Yet there's no question that 
the current system is dangerous for all 



physicians are much freer under a 
we'll be able to sustain it for a decade. 

sides — for consumers, providers, and the 
go\'ernment — and that it is burdening 
e\'eryone with serious cost problems. 

While it's true that, in the short run, 
physicians are much freer under a fee for 
service system, I find it hard to beUeve that 
we'll be able to sustain it for a decade. If 
physicians want to regain control of their 
destiny, they'll need a reimbursement sys- 
tem that mo\cs away from fee for service. 
The capitation system that was created in 
the mid 1990s was too restrictive. The 
managed care companies .squeezed it too 
much and made it intolerable. But I beUeve 
that a properly designed capitation .system 
is actually better for physicians. 

I think that if you put physicians in 
charge of both fees and utilization — as 
opposed to putting some third part)' in 
charge — you will wind up either with a 
reintroduction of insurance companies 
running the system or the go\'ernment 
taking it over. I fear that the current sys- 
tem essentially puts no one in charge. 

WELCH; Health care in the United 
States, at this time, is unmanaged and, 
because of that, we have the least effi- 
cient system in the world. We won't be 
able to accomplish anything until we 
address intrinsic inefficiencies: first, 
administrative overhead, which soaks up 
an incredible percentage of the premium 
dollar just for transactional costs; sec- 
ond, all those antiquated ways of taking 
care of people, including paper records 
and reimbursement on a per-visit basis; 
and third, our lack of a rational system 
for selecting and deploying new tech- 
nologies based on cost effectiveness. 

BLUMENTHAL: A new generation of econ- 
omists is raising an alternative hypothe- 
sis. They're saying that health care is 
worth what we're paying for it. Sure, it's 
expensive and uncontrolled. But it's the 
best investment this country could make. 

NEWHOUSE: Or any country, for that 
matter. Every nation is buying into the 
capabilities of medicine. It's not the case 
that, if you go to Germany, the UK, or 
Canada, there are no MRI machines. 
There are just fewer of them. There is 
less of everything, in general, which is 
why they spend less than we do. But 
they are buying the new capabilities as 
they come out. 

There is plenty of evidence that we 
could reduce costs vvithout gi\ing up 
much. The problem is figuring out how 
we're going to reduce them and who is 
not going to get their spending. It's also 
not true that we don't ration care. We 
just do it implicitly: the uninsured and 
Medicare beneficiaries get less care than 
other people do for similar problems. 

ALTMAN: Yes, we ration in that some 
people aren't insured. We also ration 
according to geography; people who live 
in cities with big medical centers have 
greater access than those in rural areas. 

But, for the most part, this country 
does have much better access to the new 
technologies than any other nation. I have 
a good friend who lives in Canada, a man 
with a heart condition for which he 
would probably undergo open-heart 
surgery fairly quickly in the United 
States. But in Canada he'll probably stay 
on a waiting Ust for six months to a year. 
The consensus is that, although his con 
dition has greatly restricted his mobili 
ty, it's not life threatening. 

The Canadians have hmited the num 
ber of places where this kind of opera- 
tion takes place. And England has many 
instances of people needmg chemothcra 
py or suffering from renal disease who 
are on treatment waiting lists. 

When you ask people in this country 
whether they'd be willing to put up with 
that kind of rationing in return for the 
greater good, they don't like it. Americans 

want the benefits of the new technolo- 
gies, and they don't want to see the med- 
ical care system held back. But that's dif- 
ferent than saying that it should be total- 
ly unregulated, because they're also 
telhng us that they're having difficulty 
affording the growth. 

If the price we pay for universal cover 
age is a limited amount of rationing that 
slowed the growth rate but didn't stop it, 
I think Americans would get used to it. 

BLUMENTHAL: The argument I hear 
being made is that hmiting health care 
might be bad for us as a society because 
people are buying it for good reason: It's a 
better investment to buy a stent for your 
coronary artery than another car or com- 
puter, because it increases your produc- 
tivity, improves the quahty of your life, 
and even extends your life. It's an argu- 
ment that physicians have been making 
for a long time. So, I think the real ques 
tion is not so much the rate of growth, 
which may be justifiable, but the level of 
inefficiency. Now that, of course, gets us 
into tough terrain about how to deter- 
mine what's misuse of beneficial care. 

ALTMAN: What would happen if we 
were to slow our system down a bit and 
have fewer options? Now, no one would 
suggest we should not be doing extensive 
amounts of open-heart surgery or that we 
shouldn't use stents. The question is: once 
we make these things available, do they 
need to be everywhere? 

The other issue is whether we should be 
doing open-heart surgery on 95- year-olds, 
or even 90-year olds. Other countries don't 
do that. They're allocating resources while 
we're making tradeoffs without really hav- 
ing much control over those tradeoffs. 
In countries where all the money flows 
through a single spigot — the govern- 



percent of physicians we 
by retiring early, shifting to administration, 

ment — society is saying, in effect, we'd 
rather spend our money in other sectors. 

BLUMENTHAL: Maybe we could achieve 
consensus on ways to make it possible 
for people who deliver care to have more 
freedom to make the right choices. Capi- 
tation was introduced in the context of 
overspending but it failed because it was 
used as a club to reduce costs rather than 
as an incentive to improve quality, physi- 
cian autonomy, and patient choice. 

NEWHOUSE: I agree with the Institute of 
Medicine's view that it's impossible to 
make headway without achieving greater 
organization than we have today. And I 
think this is where the medical profession 
can really exert leadership. 

WELCH: For the past few months, the 
Massachusetts Medical Society has been 
looking into issues of unnecessary admin- 
istrative overhead. For instance, at Mass- 
achusetts General Hospital, for every four 
physicians, we need one billing speciahst 
and two referrals and authorization spe- 
ciahsts. So insurers and pro\iders togeth- 
er are trying to identify elements of 
administrative overhead that both sides 
can agree are unnecessary. The surprise to 
everyone is how much agreement there is. 

The aim is to move this iniriative for- 
ward from saving money on administra- 
tive costs to developing a statewide, fuUy 
integrated electronic platform for health 
care, creating systems of coordination 
and integration of care across inpatient 
and outpatient interfaces. So, it's the right 
care, at the right time, and in the right 
place, using predictive modeling to iden- 
tify high-risk patients and to intervene 
earlier in the trajectory of their iUness. 

We also need to estabUsh consensus 
on targets of quality and safety. Because 
right now, we've got a Tower of Babel. 
Every insurer has different guidelines, 

and there's no way physicians can keep it 
straight as to who wants them to do what 
for how much money. 

And finally, we need to create incen- 
tives for health, not for the visit. We blew 
capitation the first time around not 
because capitation was bad, but because 
we did it in a way that put physicians in 
an impossible situation. We need to pro- 
vide them with incentives to innovate 
and to deliver a better le\'el of care at a 
lower cost. 

BLUMENTHAL: We've gone through a 
period in which integration was the 
mantra for saving money. There were 
many mergers and acquisitions, legal bills 
were run up, and many backroom func- 
tions were consohdated. But it seemed 
neither to reduce costs nor to change 
practices. So people have a bad taste in 
their mouth, right now, about integration. 

ALTMAN; I agree. Just as we learned the 
wrong lesson about capitation, we 
learned the wrong lesson about integra- 
tion. Integrated systems would have 
worked better if reimbursement prac- 
tices hadn't changed such that those sys- 
tems were hemorrhaging money. They 
were buying physician practices, which 
turned out to be very expensive. They 
bought nursing homes and homecare 
agencies which, when reimbursements 
changed in the federal government in 
1997, also became losers. 

Let's face it, truly integrating and get- 
ting people to work together is a long- 
term process, and it probably would have 
taken a generation to make it succeed. So 
we now have many more di\'orces than 
marriages. And the ones that are still mar- 
ried often live in separate houses. Informa- 
tion technology allows that, because it 
doesn't require you to be in the same 
building or e\'en the same city, as long as 
you're willing to work together. So, maybe 

we'U find an alternative model. But I think 
we've lost a valuable organizational struc- 
ture as a result of this disintegration. 

BLUMENTHAL Many of the 20,000 physi- 
cians in Massachusetts are in indi\idual 
practice and would probably be unhappy 
at the prospect of a future of integration. 
They want to be free to choose. 

WELCH: If integration worked any better 
than what they have now, they would 
leap at it. There is a huge amount of dis- 
satisfaction out there among physicians. 
We're having a workforce implosion. The 
vacancy rate in cardiology in Massachu- 
setts is 17 percent, for example. More 
than half of the hospital departments we 
surveyed this year are curtailing ser\ices 
because of physician shortages. 

One in three physicians in Massachu- 
setts tells us that, if things don't get better, 
they will leave the state. Thirty percent of 
physicians we surveyed are trying to leave 
the practice of medicine by retiring early, 
shifting to administration, or changing 
professions altogether. So, there's a rush 
for the door. On the face of it, it looks like 
it's the ratio of income to cost of h\ing 
that's the main dri\'er for this unhappiness. 
But underneath that is despair over all the 
impediments to pro\iding good care. 

BLUMENTHAL: With the Center for 
Health System Change in Washington, 
DC, Bruce Landon and I recently did 
some research on physician satisfaction 
that showed that, nationally, the most 
important determinant of satisfaction is 
not income, but autonomy — the freedom 
to make decisions and the opportunity to 
dehver the best quahty care. 

ALTMAN: I do think we need to acknowl- 
edge that the situation has been improv- 
ing. I understand the cost of U\'ing prob- 
lem in Massachusetts, and I understand 



surveyed are trying to leave medicine 
or changing professions altogether. 

the impact of skyrocketing malpractice 
insurance rates. But the managed care 
companies that continue to function want 
to be kinder and gentler. The strong pres- 
sure from managed care to regulate the 
behaNior of physicians is way down. In 
terms of autonomy, physicians today are 
better off than they were fi\'e years ago. 

WELCH: Yes, but it's an Ulusory free 
dom, because the system itself is so dif 
ficult in terms of being able to take good 
care of people. I think physicians are 
walking out of the profession, to some 
extent, simply because they feel like 
they can't do the job they have always 
wanted to do, because the system has 
become so antiquated, so paper-bound, 
so inefficient and fragmented. 

NEWHOUSE: Whatever changes will be 
made, they can't be one-size-fits-all solu- 
tions, because what works for a major 
Boston teaching hospital won't work for 
a small town practice in the western 
part of the state. ■'Vnd that's just the 
di\'ersity of Massachusetts, never mind 
the country at large. 

I like elements of capitation, but it has 
some substantial drawbacks. Since we 
don't know how to perfectly tailor capi- 
tation to the individual, there are incen- 
ti\'es to cream the good risk and dump 
the bad. And in a capitated system, you 
don't get paid anything for doing more. 
So I would advocate a mixture of capita- 
tion and fee for service. Capitating indi- 
vidual physicians for all services would 
terrify me, whereas capitating a large 
group is another matter. 

ALTMAN: We need to bring physicians 
back into the decision making process, 
but without an open ended budget. 

BLUMENTHAL; In the 1990s, there was an 
attempt to redesign the health care sys- 

tem without im'oh'ing physicians on the 
assumption that they were part of the 
problem, that their spending, test order- 
ing, and habits were counterproductive. 
.■\nd capitation was seen as a solution. 

The public taught us that they didn't 
like that. When the mo\ie As Good As It 
Gets came out in 1997, whenever Helen 
Hunt's character referred to "that damn 
HMO," the audience w'ould break out in 
applause — and, as far as I can tell, even in 
Boston, the audience members weren't all 
doctors! There was a genuine popular 
rebelhon against the idea that doctors 
were not in control of their patients' care. 

So physicians should feel good about 
the alliances they have created with 
patients. But they also need to realize 
that they're not the only ones under 
stress; patients are under increasing 
stress as well, as they face escalating 
costs. The question that physicians have 
to answer is how to organize them 
selves, because they're not easy to orga- 
nize, constitutionally. 

ALTMAN: If the system continues unregu 
lated, no amount of goodwill on anyone's 
part wiU stop the escalating costs, because 
every sector of the system wiU operate in 
its own self-interest. Patients want the 
best; physicians want to provide the best. 
Other countries limit the availabihty of 
resources by restraining the supply side. 
They say, "Doctor, you're free to do any- 
thing you want. But there are only two 
open- heart units. If you send ten patients, 
someone wiU have to create a priority 
list." That's how they limit spending. 

WELCH: If we were to come back to this 
table in the spring of 2008, how optimistic 
are you that things would be better? 

NEWHOUSE: The capabilities of medi 
cine will definitely improve. Costs will 
be higher. Probably the number of unin 

sured will be marginally greater, unless 
the economy picks up a lot faster than I 
think it will between now and 2008. 
Much will depend on how the overall 
economy performs. 

ALTMAN: I think we will be significant- 
ly worse off by 2008. The number of unin- 
sured will be significantly higher, and the 
Medicaid program will likely be in much 
worse shape. Even if the economy turns 
around, it still won't be easy to buy back 
what we've lost. We need an active, seri- 
ous intervention by the government, not 
to take the health care system over, but to 
be a force for good. 

BLUMENTHAL: I agree— things will be 
worse by 2008. But I think, by 2015 to 
2020, we will have a significantly revised 
and improved health care system. I'm 
assuming that these conditions will get 
bad enough over the next ten years for 
that to happen. 

WELCH: I think the same thing will hap- 
pen, but faster, because the cost escala- 
tion is crushing the system. And the dys- 
functions in the system are destroying 
both patients and physicians. So I hope 
this evolution will be much more rapid 
than you predict, David. 

BLUMENTHAL We should keep in mind 
another evolution that will happen at the 
same time: the ability of physicians to 
make a difference in the hves of patients 
will grow rapidly, maybe even exponen- 
tially, over the next five years. Both the 
life expectancy and health status of 
.Americans will continue to improve. And 
if you can isolate yourself from the chaos 
of health care financing, the rewards of 
being in medicine will be substantially 
greater than they've ever been in history. ■ 










\\ have some 30 years ago, before medical school: I arrive at my office 
ff in a pleasant suburban building with plenty of free parking, stride 
through the waiting room greeting smiling patients by name, put on my 
white coat, and begin a day of bringing comfort to the suffering, hope to 
the despairing, and kindness and respect to all. Then I wake up. 1 What 
has happened to my dream? What has become of the 36-year'old house- 
wife and mother who began her medical student days as "the oldest 

person Harvard had ever accepted," with the 
goal of caring for each patient as though he 
or she were the most important person on 
earth? What has happened to the aspiration 
of providing selQess service until the point of 
dying suddenly at work, like the giants of 
medical mythology? 

Medicine has changed. The world of those 
dreams may never have fully existed in any 
era, but today's health care bears little resem- 
blance to the practice of medicine — and the 

experiences of patients — in the 1970s. Thirty 
years ago, physicians were called doctors, not 
providers. "Health" and "care" were still two 
separate words. "Health care crisis" referred 
to illness, not economics. 

After graduating from HMS and training in 
internal medicine, I set out to live my dream. I 
briefly considered going on to a subspecialty, 
as HMS graduates were expected to do. Yet I 
had wanted since childhood to practice med- 
icine in a community setting where I could 




ifl «"■"'- 

UNMANAGED CARE: Burdened by financial pressures, Latham 
^as forced to pack up her practice at Emerson Hospital. 

treat men and women, old and young, the 
very ill and the nervous healthy, and where I 
could truly get to know my patients. Besides, 
v\ith fi\'e teenage sons and an astronomer 
husband, all of \\'hom had made enormous 
sacrifices to see me through medical school 
and residency, it was time to start a practice. 

I was in\ited to join a wonderful, kind, and 
modest internist in Concord, Massachusetts, 
who practiced excellent medicine in exactly 
the way 1 had emisioned. It is hard now to 
beheve that we functioned as we did less than 
20 years ago. We paid httle attention to the 
business of medicine: wc accepted as payonent 
fresh \'egetables and homemade pizzas from 
patients who were short on cash. We spent 
the time to get to know our patients and to 
understand their physical diseases in the con- 
text of their social and psychological Hves. The 
waiting Ust to join our practice grew. 

We decided to take on a few more patients, 
hut then had to hire an extra secretary to 
keep up with the phone calls. Once we had 
a larger staff, we agreed to accept yet more 
patients. Soon a business manager seemed 
necessary We found ourselves working 
longer and longer hours, sleeping less and 
less, and becoming increasingly unavailable 
to our famihes. Through all this, still more 
people wanted to become our patients. But a 
groviing number of them were becoming 
members of HMOs through their employers, 
and an ever-dwindling number of the unin- 
sured could afford to pay. Our margins shd. 

Neither my partner nor I had received any 
training in the business of medicine during 
medical school or residency, and little infor- 
mation was available in print or in post- 




medical system tends 
patients and to encourage quick procedures 

LAST CALL: Latham says goodbye to two long-time patients on their 
and her — final appointment at Emerson Hospital. 

graduate seminars. Nor did we ever find the time 
to sit down with accountants or consultants to 
address how we might better manage the finances 
of being in practice; we were far too busy taking 
care of patients. 

Reimbursements from the insurance companies 
continued to shrink, and the burden of filling out 
forms and telling patients "no" when they request- 
ed this test or that medication fell to us. We spent 
increasingly more time on triplicate forms and 
duplicative paperwork that did little or nothing 
to enhance patient care. Overhead costs rose, and 
rose again. Year after year our incomes fell, even as 
we put in longer hours. At one point, standing in a 
pizza shop, I saw an advertisement on the wall for 

a new manager and realized that the position 
offered more per hour than I was making. 

My partner and I both loved what we were doing, 
and our spouses and children stuck by us. Only 
gradually did we realize that neither of us could 
continue to practice quality medicine when we 
were rushing through our patients, ending the day 
too exhausted to dri\'e home safely, and sacrificing 
opportunities to see our fanulies. 

During that period, I was unexpectedly recruit- 
ed to become chief of ambulatory medicine at 
West Roxbury Veterans Administration Hospital. 
While I would be seeing some patients in my own 
clinic, I would spend most of my time teaching stu- 
dents, interns, and residents from various Harvard 
programs and overseeing all of the primary care 
and specialty clinics. I jumped at the chance. But 
packing up my medical equipment, my pictures, 
and my entire work life was hard. And saying 
goodbye to my patients, my mentor, my hospital, 
and my community felt awful. 

Although the VA position was wonderful in 
many ways, over the years I found myself increas- 
ingly busy with administrative detail and decreas- 
ingly available to my patients and students. Even- 
tually, I was offered a major promotion that would 
have meant giving up patient care entirely. 

Instead, in 1992, I returned to private practice. 
The then chief executive officer of Emerson Hospi- 
tal in Concord had offered me the opportunity to 
join a planned group of salaried primary care 
physicians directly affiliated with the hospital. In 
the early 1990s such groups were being touted 
nationally as a win win solution for hospitals and 
for primary care physicians. I eagerly returned to 
the community. 

The patients flocked to our practices, which 
were always oversubscribed. The hospital-based 
groups grew rapidly — some 30 physicians joined 
Emerson Practice Associates; my personal group 
consisted of five internists. Meanwhile, I had 
arranged for the hospital to become a site for the 
HMS primary care clerkship, so I could continue to 
teach — and offer other physicians the opportunity 
to teach — the outpatient medicine that I loved. 

But reimbursement continued to be set by out- 
side parties: Medicare, Medicaid, and the health 



to penalize physicians for spending time with 
and testing over hstening to and examining the sick. 

insurance companies, with little or no physician 
input into the rates. Expenses escalated: malprac 
tice insurance, rent, telephones, utilities, staff 
salaries and benefits, supplies, medications. The 
combination of fixed reimbursement and escalat 
ing overhead costs led to negative balance sheets 
for the hospital. We physicians came to realize that 
hospital management consultants were often even 
less well equipped than we were to understand 
and effectively control office expenses. Instead the 
mandate was always to see more patients faster, to 
increase income. Unfortunately, that mandate not 
only didn't improve finances if the per patient 
reimbursement was less than the cost of delivering 
the service, but it also often meant sacrificing the 
quality of the care being delivered. 

Emerson Hospital, like hospitals across the 
nation, viewed affiliated practices as potential 
profit centers, not cost centers, even though such 
practices provided the institution with many 
patients who previously had used physicians else 
where and now, by using the hospital's outpatient 
and inpatient services, contributed to its bottom 
line. And direct profits from office practices were 
not to be. The financial realities of maintaining an 
office practice in Massachusetts with its high pen 
etration of managed care and associated low reim- 
bursement rates, combined with the state's high 
cost of doing business, led Emerson Hospital, like 
many hospitals, to divest itself of affiliated prac- 
tices by the year 2000. 

These days I continue to enthusiastically greet 
my former patients when I see them. Sadly that's 
not in my waiting room, but only in the grocery 
store, at church, or in the town library. Instead of 
caring for individual patients, I spend my days 
working on initiatives related to patient safety and 
impro\'ing the quality of medical care. While those 
are important issues that ultimately benefit larger 
groups of patients, I now function as the physician 
of my dreams only in my dreams. 

Over the past decade, while in active practice 
and since, I have spent a great deal of time working 
to try to improve the health care system for both 
physicians and patients. Today's medical system 
tends to penalize physicians for spending time 
with patients and to encourage quick procedures 

and testing over listening to and examining the 
sick. Enormous amounts of money are spent on 
administrative regulations and programs to con- 
trol costs, while medical care itself is underfunded. 
We are in an era in which we can save the lives of 
the formerly hopelessly sick and deliver incredibly 
complex care thanks to awe-inspiring technical 
advances, yet many working people lack the 
resources to take a febrile child with a sore throat 
for care before the strep pharygitis becomes 
rheumatic fever. 

We can ill afford to look at the current state of 
the health care system and simply shrug, declare the 
practice of medicine hopeless, and retire early. And 
we can ill afford to ignore the changing goals of young 
physicians. Many of them now seek law or busi- 
ness degrees or look for corporate positions, while 
the number of those choosing careers in medical edu- 
cation, basic research, or patient care decreases. 

Whether our personal skills as physicians are 
in compassionate listening, meticulous micro- 
surgery, or innovative biotechnology, we must 
lead the state and national debate on reform of the 
health care system. Many of us frequently feel too 
overwhelmed by our day to-day responsibilities 
to take on anything else. But we cannot ignore the 
larger issues. We are the ones who best under- 
stand medicine and who can best advocate for our 
patients and our profession. 

As physicians, no matter what our specialty, age, 
or pohtics, we must work together to revamp the 
system. We need creative reforms that move us 
into the future and encourage new ideas. We need 
change that allows us to continue to put the high- 
est priority on deli\ering the best care that we can 
to each human being who comes to us. While we 
sleep, we can dream of an idealized past that may 
or may not have ever existed. But while we are 
awake, we must dream of the possibihties of the 
future and take action to realize those dreams. ■ 

Virginia Latham '8 J is a past president of the Massachusetts 
Medical Society, the Emerson Hospital medical staff, and the 
Massachusetts branch of the American Women's Medical 
Association, and a current delegate to the American Medical 
Association, roles in which she has emphasized patient and 
physician advocacy. 







// Tames 
VV Cashel 


his medical training with a master's 
degree in pubUc poUcy through a joint 
program between HMS and Harvard's 
Kennedy School of Government, the 
combination struck some as an unltke- 
ly, if not incompatible, career recipe. But 
Cashel, a student of history, points out 
that he was in good company: "Three 
of our nation's Founding Fathers were 
not only prominent in government, 
but they were also physicians." 

Capitalizing on a similar spirit of 
versatility, Cashel has blended medical 
knowledge with poUtical know how to 
chart a course not readily conceivable to 
many physicians. "I've spoken to doctors 
who find it difficult to conceptualize 
anything outside of academic medicine," 
he says. "When I graduated, I could count 
on one hand the number of alumni who 
weren't going directly into residency" 



But that trend is changing, in part 
because of innovative models of career 
crossover such as Cashel's. After 
receiving his joint degree, Cashel 
went to Washington, DC, where he 
co-founded the Eurasia Foundation, 
which funds programs that build 
democratic and free market institu 
tions in the New Independent States 
of the former Soviet Union. The foun- 
dation quickly grew from three staff 
members to more than 100 in seven 
countries, with an annual budget of 
more than S25 million. 

Ready to mo\-e on to new challenges, 
Cashel became excited by the potential 
impact of the Web on medicine and 
public policy issues. In 1996 he founded 
Forum One Communications to take 

advantage of that 

As chair- 

^g,^ ... ...... promise. 

man, Cashel collaborates with agencies 
that are working to soh-e pressing 
problems in such areas as the emiron 
ment, international development, and 
medicine, guiding them to use the 
Internet to fulfill their missions and 
achieve a broader international reach. 
He CO- directs the International .AIDS 
Economics Network website, for 
example, which links more than 7.000 
HI\7AIDS pohcymakers worldwide. 

Cashel's medical background played 
a key role in this success. 'A medical 
degree offers training in the natural 
sciences, provides extensive expo- 
sure to the social sciences, and teach- 
es critical thinking and the manage- 
ment of large amounts of informa- 
tion," he says. 

"I'm working increasingly at the 
intersection of medicine, technology, 
and pubUc pohcy," Cashel adds. "And 
when I speak to physicians now; I often 
hear envy in their voices as they talk 
about the possibihty of working in an 
emironment that's not strictly medi- 
cine, to get away from some of the cur- 
rent constraints of the profession." ■ 



of leisure to read the Wall Street Journal. As she scanned the headlines, she 
became increasingly unsettled. "One of the major stories was about an 
SEC investigation," Jaya,suriya says, "and I suddenly became aware that 
I didn't have a clue about the business world or about economics. I 
didn't even know what the Dow Jones industrial average was. I had been 
thinking that medicine was the be-all and end-all, but at that moment 
I realized the relevance of business and economics to medicine." 

That was in the mid 1980s, when both biotechnology and managed care 
were shaping medicine in new and surprising ways. "A lot was changing," 
Jayasuriya says, "and it became clear to me that there would be a growing 



need (or people who could bridge the 
gaps and span medicine, biotechnology, 
and the pharmaceutical industry." 

jayasuriya was about to challenge her 
belief that all the best and brightest 
people went into science and medi- 
cine. After completing her medical 
degree, a doctorate in microbiology and 
molecular genetics from Harvard, and 
an internship in pediatrics at Children's 
Hospital in Boston, she surprised her 
mentors and colleagues by entering 
Harvard Business School in 1991. There 
she discovered that the broader and 
more integrative outlook suited her per- 
sonality much better than medical prac- 
tice would have. "I wanted to know 
more about the workings of the world," 

she says, "and to play in a bigger arena, 
which business allows you to do." 

Jayasuriya has since worked with such 
companies as Skyline Ventures, which 
specializes in hands-on investing in 
early stage health care companies, and 
Genomics Collaborative, Inc., a develop- 
er of proprietary research tools and ser- 
vices. Now living in California, she 
works with ATP Capital, a New 
York-based private equity fund dedi 
cated to making investments in the life 
sciences. She also consults on projects 
sponsored by the National Institutes of 
Health's Immune Tolerance Network 
and at the University of California-San 
Francisco. "I share the dream," she says, 
"that many venture capitalists have: to 

help build successful companies that 
will make available important inter- 
ventions, ones that will help people stay 
in good health and reward im'estors." 

Despite her devotion to her chosen 
career path, Jayasuriya has no regrets 
about earning a medical degree or a doc- 
torate, largely because they gave her the 
expertise and experience needed to 
make critical business decisions. "I use 
what I learned at HMS every day," she 
says. "I'm constantly evaluating business 
plans based on cutting-^edge science. My 
scientific knowledge plays a big role in 
selecting comparues that are promising." 

Jayasuriya is fuUy engaged as a ven- 
ture capitalist, but also maintains her 
medical credentials. She is Hcensed in 

// John 

W Frpii 



Business School, graduating as a Baker 
Scholar and co-author of a New York 
Times bestseller. The Official MBA Hand- 
book But his decision to go to business 
school had earned him a cold reception 
from many at HMS, who resented 
Freund for ha\ing taken up a coveted 
admissions slot only to — as they per- 
ceived it — turn his back on a medical 
caUing. "It wasn't at all a popular thing 
I did," Freund admits. But what he 
went on to accompUsh has probably 
changed their opinion of him — and 
broadened their definition of a voca- 
tion of healing. 

Freund enjoyed science in college 
and his father was a surgeon, so med- 
ical school seemed a natural choice. 
But from the start, he was profoundly 
unhappy. "Everybody hates the first 
two years of medical school," his father 
reassured him. By the time Freund 
made it to rotations, though, he had 
realized that medicine wasn't for him. 



Massachusetts and California as a gen- 
eral practitioner, and she earns her 
continuing medical education credits 
e\'ery year. She works with the non- 
profit organization InterPlast, whose 
programs allow volunteer physicians 
to provide free reconstructi\'e plastic 
surgery to children and adults in dc\'el 
oping countries. Jayasuriya collaborat- 
ed with InterPlast to create a program 
in Sri Lanka, her native country, where 
she tra\'els every year to take care of 
patients. This experience helps her to 
stay connected to clinical medicine in a 
meaningful way. "My decision to pur 
sue a business career wasn't a turning 
away from medicine," she says, "but an 
awakening to the larger world." ■ 


After graduating from business 
school, Freund got his start in venture 
capital as the original health care part 
ner at Morgan Stanley Ventures. Then, 
after several years as the executive \ice 
president of an ultrasound company, he 
CO founded Intuitive Surgical in 1995. 

Intuitive has created the da X'inci 
Surgical System, robotic technology 
that allows surgeons to perform gener- 
al laparoscopic surgery, thoracoscopic 
surgery, and laparoscopic radical 
prostatectomies. "It allows a number of 
minimally in\'asi\'e procedures to be 
done that could not be done with any 
other technology," Freund says. The 
system is in use in major teaching hos- 
pitals throughout the United States. 

Once Intuitive Surgical was off the 
ground, Freund returned to venture 
capital. He now serves as managing 
director of Skyline Ventures, an early- 
stage investor that helps establish 
health care companies. Despite his 
success, Freund says that profit has 
not been the driving force in his career. 

"I've made contributions to mcdi- 
cine at least as important as those I 
would have made if I'd gone into clini- 
cal practice or research," he says. "I can 
return to HMS knowing that I did 
something significant with my medical 
education. I'm proud of that." ■ 



Leon Palandjian '00 was still in high school, and it wouldn't come to 
fruition for ten years. But by the time Palandjian neared the end of his 
medical education, so, too, was the Human Genome Project approach- 
ing completion — and captivating young doctors and scientists eager for 
exploration, new map in hand. 

Palandjian, a cell biology research fellow at HMS who had worked on 
RNA splicing, found himself on the edge of a brand- new scientific terrain; 
his chosen field of genomics hadn't existed before the Human Genome 
Project created it. He was intrigued by the potential of gene therapy to 
change the way disease is diagnosed and treated — indeed, to alter the 
practice of medicine itself. 

"I sensed a huge revolution about to happen in biotechnology," 
Palandjian says, "the discovery of new genes, a set of technology applica- 
tions that would lead to novel therapeutics and diagnostics. I didn't go 
into business because I was dissatisfied with medicine, but because I felt 
compelled to work in biotechnology and medical technology." 



Palandjian had entered HMS with 
a business background that included 
three years as a management associate 
at SmithKline Beecham, but also with 
an open mind about a career as a physi- 
cian. He had found himself drawn to 
medical school during his stint in the 
pharmaceutical industry: "I had become 
more interested in health and wanted to 
pursue that in a deeper way than I could 
have in a business context." 

During his final year of medical 
school, Palandjian accepted a position 
with Flagship Ventures, a biotechnolo- 
gy venture capital firm based in Cam- 
bridge, Massachusetts. There he found 
the opportunity to combine his pas- 
sion for medicine with his business 
acumen. He worked hard to help buUd 
Flagship's portfolio, which now com- 
prises a dozen life science companies. 
One of these. Adaptive Therapeutics, 
focuses on novel classes of antibiotics 
for a spectrum of infectious diseases. 
From a platform technology developed 
by a professor at the Scripps Research 
Institute, Palandjian led Flagship's 
efforts to co-found the company, 
license the technology, write the busi- 
ness plan, and provide the capital. He 
now works closely with several other 
Flagship companies that are leveraging 
applied genomics technologies to 
develop new products. 

"The common theme in the work 1 
do is early-stage entrepreneurship and 
venture investing," he says. "These 
companies serve as a bridge from 
bench research to the marketplace. 
And my medical background allows 
me to recognize the unmet needs in 
the marketplace." 

Palandjian relishes life on the cut- 
ting edge of biotech and believes that 
one of the most fascinating and reward- 
ing aspects of helping a biotechnology 
company succeed is fostering cross- 
polhnation among discipUnes. "In aca- 
demics, people tend to work in sHos of 
expertise," he says. "But in the context 
of a venture-backed company, it's pos- 
sible to get people from many different 
disciplines to work together to achieve 
a focused common goal. You can get 
physicians in the same room with 
computer scientists, chemists, biolo- 
gists, and business managers, and inno- 
vation emerges at the intersection of 
their different disciplines." ■ 



decade career in academic medicine for the world of private enterprise, 
he was following the old adage, "Leap, and the net will appear." Half of his 
friends supported his decision, but the other half thought he was out of 
his mind. "People who made such choices used to be seen as failed doc- 
tors," Lange says. "Luckily for me, that's not true anymore." 

As chief executive officer of CV Therapeutics in Palo Alto, California, 
Lange has positioned himself at the helm of a company that is pioneering 
a new biomedical discipline; molecular cardiology. "Drug discovery and 



development is the best team sport," 
Lange says. "You ha\'e to integrate all 
your skills and depend on all disci- 
plines, from genomics to marketing." 
But despite his love of teamwork, 
Lange began his career as a solo player. 

Lange's initial focus was molecular 
research in cardiology, which only a 
handful of scientists were pursuing 
during the 1970s. In 1980 he joined the 
faculty of Washington University, 
where he spent 12 years and became 
chief of cardiology. Lange's research 
specialty was rare and desirable, and he 
was widely recruited. He transferred to 
the Jewish Hospital of St. Louis, where 
he ran a di^dsion of about a hundred 
people and a large laboratory. This tra- 
ditional position e\'entually led Lange 
away from the well trodden path. 

"Over time, the job came to have 
a great deal of visibility," Lange says. 
"For the hospital to be successful, car- 
diology had to be successful. I was 
good at attracting business and 
adding new people, forming relation 
ships with practice groups. But 1 had 
no control over the money that came 
in. I was constantly begging the hos- 
pital for money for programs." 

When Lange received an offer to be 
the head of medicine at another major 
hospital, he decided to make a change. 
He joined a venture group with the 
vision of a broad-based cardiac tech- 
nology company; in 1992, that vision 
developed into CV Therapeutics. The 
company has since developed pro 
grams in cardiac metabolism, adeno- 
sine receptor research, atherosclerosis, 
cell cycle inhibition, and cardiovascular 
genomics. CV Therapeutics went pub 
lie in 1996 and now has four products in 
chnical development. 

"I went to college in the late '60s," 
Lange says, "and like most of my class- 
mates, I hated big companies. But bio- 
tech changed everything. Small biotech 
companies can focus and make deci- 
sions and move. Dyed-in-the-wool 
academicians like myself have begun to 
start companies where premier acade- 
mic research can take place." ■ 


^ ^ Sherwin 


Sherwin '74 recalls exclaim- 
ing as he read the class book 
at his HMS tenth reunion. 
"Somebody in our class is 
stuck doing insurance physi- 
cals!" Glancing at the single 
hsting for "industrial physi- 
cian" that had elicited Sher- 
win's surprise, the classmate 
who had compiled the book 
replied, "Actually, no, Steve. 
That's you." Says Sherwin, 
"He didn't know a better way 
to categorize what I was 
doing. That's how unusual a 
career in biotech was in 
those days." 

Sherwin had started out 
along a more conventional 
path, with an interest in 
medical oncology that took 
him to the National Cancer 
Institute. But in the late 1970s, he began hearing more and more about the 
brand-new biotechnology industry. "From the late '70s through the mid- 
'80s, biotech was regarded as so far out there as to be Httle more than a 
dream," Sherwin says. "What drew me to it was my behef that I could pur- 
sue the apphcation of these new technologies to the field of cancer medi- 
cine better and faster in a biotech company than I could anywhere else." 

He left traditional academic medicine in 1983 to serve as associate 
director of clinical research at Genentech, then a startup of about a hun- 
dred employees and now one of the world's leading biotechnology com- 
panies. Although Sherwin had had no previous inclination to explore the 
business world, by the late 1980s he found himself becoming interested in 
topics peripheral to medicine — investor activities and business transac- 
tions, for example. In 1990, when Genentech had grown to a staff of 
around 2,000, Sherwin decided to explore the next wave of technology — 
gene and cell therapies — by starting up a new, smaller company in San 
Francisco, Cell Genesys, where he now serves as chairman and CEO. 

During his early years at Cell Genesys, Sherwin continued to see 
patients as an attending physician at UCSF and San Francisco General 
Hospital, but he ultimately hung up his stethoscope in the mid-1990s, when 
the demands of running his company — and a second company, Abgenix, 
which he co-founded — proved all-absorbing. He still misses everyday clin- 
ical practice, but has no regrets about following his medical interests into 
biotechnology, or about the business skills he has acquired along the way. 
"I've conducted more business transactions in my life than I could 
ever have imagined," Sherwin says. "During medical school and residen- 
cy, I could never have predicted the path that I've traveled, but I feel very 
lucky to have found it." ■ 



woman from the 
Persian Gulf region, 
clad in Islamic dress 
meant to enforce 
modesty among 
v/omen, was one 
of Farrokh Saidi's 
patients in 1962. 

A surgeon finds his introduction to medical 

practice in his ancient homeland eased by the wisdom 

of his Harvard Medical School professors 

by FARROKH SAIDI it was early in the morning 
when our small group of third-year HMS students made its 
way to the fluoroscopy room at Beth Israel Hospital, escort- 
ed by the chief of radiology, Felix Fleischner. When we 
arrived, a patient was already on the table and the Ughts were 
off. Fleischner proceeded to move the fluoroscopic screen 
over the patient's body while we watched, not really under- 
standing what was happening. ^ "Now hold your breath," 
Fleischner instructed the patient as he continued examining 
her stomach. After what seemed an impossibly long time, he 
briskly informed the patient: "Now you may breathe again." 




v\^isdom of such HMS 

mentors as Fuller 

Albright (right) and 

Edward Churchill 

(above, second 

from right) proved 

invaluable in easing 

Saidi's entry into 

medicine in Iran. 

The lights came on and, before the next 
patient could be wheeled in, my closest buddy, 
Lou Rashin, cleared his throat and dared to 
ask how the patient could possibly have been 
expected not to breathe for so long. Fleischner 
seemed prepared for the question and gave us 
an answer — and a lesson — I would never for- 
get: "As a doctor, you should always make sure 
others realize you are in charge!" 

That was in Boston, back in 1952. 

Cut to the spring of 1980 in the capital city 
of Tehran. We were well into the Iranian 
Islamic Revolution, which had exploded the 
pre\ious year. His Imperial Majesty, the Sha- 
hanshah, had fled the country two months 
earlier, bringing to a dramatic close 25 cen- 
turies of uninterrupted absolute monarchy. 

More riveting than anything else the revo- 
lution had brought, perhaps, was the change 
in social behavior. People looked at each 
other differently, suspicious of each other's 
true political leanings. Many feared being labeled 
anti-revolutionary, and some went out of their 
way to appear fervidly committed to the new 
regime, much as the Jacobins had done during 
the French Revolution. 

I was now chief surgeon at a general hospital in 
southern Tehran. A new cohort of medical stu- 
dents, 16 in all, had arrived that morning. These 
students seemed liveher than those in pre\dous 
groups, even a bit boisterous. I passed their atti- 
tude off as the nervousness associated with their 
first day on the ward. 

I welcomed the students into my office, where 
I asked them to sit down, di\ide themselves into 
groups of four, and wait quietly until I found 
patients for them to interview and examine. By 
the time I reappeared, they had spiUed out noisi- 
ly into the corridor. Good-naturedly, but more 
firmly this time, I ushered them back into the 
office, ordering them this time to remain inside, I 
went back to the ward and found two more 
patients with lumps and bumps. When I 
returned a second time, I discovered that the 
entire group had again poured rambunctiously 
out of the room. Now irritated, I exclaimed, 
"Damn it! I thought I told you folks to stay put!" 

A male student, who appeared to be the leader 
of the group, pushed forward and demanded in a 
menacing tone: "What did you say?" He seemed 
ready to lunge. 

A rampant revolutionary fervor had taken hold 
of these youngsters. Usually well-behaved and 
compliant, they were now challenging every 
authorit); flexing their muscles to prove to them- 
seh'cs, no doubt, that they were not behind the 
times. This was no moment for me, howex'er, to 
get lost in socio-psychological musings. I had to 
decide quickly on an appropriate response to an 
unambiguous challenge. .An apology would ha\'e 
been tantamount to capitulation and the loss of 
my teaching authorit}'. 

Remembering Fleischner's advice, I knew 
exactly what to say: "You heard me! Don't sit 
down and don't stay put if you don't want to. But 
find someone else who is willing to teach you." 
With that, I turned on my heel and walked away 
before my would-be assailant could decide on his 
next mo\'e. 

Predictably, sex-eral of the more sedate stu- 
dents caught up with me on the stairway, apolo- 
getically asking me to return and teach them. I 
was in charge again. 




fervor had taken hold of these youngsters. Usually 
liant, they were now challenging every authority. 

Native Son 

I had al\\'ays known that I would return to Iran. I 
had arrn-ed in the United States in the summer of 
1946 and reestablished my native land as my per 
manent home 15 years later. Although I naturally 
expected a transitional period, nothing could 
have dampened the culture shock I experienced 
upon my homecoming. 

HMS is an integral part of the American med 
ical complex, and almost c\'erything on the med 
ical .scene, anywhere in the country, is accessible 
to its graduates. Should an unfamihar situation 
arise and local medical authorities be unable to 
soh'e a problem, a telephone call will straighten 
things out in no time. Not so when one is 8,000 
miles away from Boston, with no long-distance 
communication a\'ailable. 

These cultural differences weighed on my 
mind as, once home, I mulled two alternatives: to 
settle in Tehran, where I had been born and 
where, with my connections, I could ha\'e easily 
melted into high society, made lots of money, and 
even embarked on a political career; or to join the 
recently established Nemazee Hospital, located 
in the remote southern city of Shiraz. 

The Nemazee had been modeled on the Amer- 
ican hospital system, and the appointment car 
ried the additional lure of teaching at the fledg 
ling Shiraz Medical School. For me, the choice 
was clear; after a month of welcoming revelry in 
Tehran, I flew to southern Iran to download all 
that I had been programmed for at HMS. 

Remennbering the Titans 

Back to my medical training in Boston in the 
early 1950s: in retrospect, it seems that who 
taught us was more important than what we were 
taught. The galaxy of out,standing teachers made 
us feel like acolytes at an ancient Greek temple of 
learning. How could anyone forget the lectures of 
Francis Moore 39 on burns and postoperative 
care? Fuller Albright '24, incapacitated as he was 
with Parkinson's disease, possessed an incredible 
knack for getting to the core of a problem with 
one incisive statement. Herrman Blumgart '21 

saw us off on our internship year with the adage 
of "chastity, po\'erty, and obedience," a valuable 
parting gift. 

The pungency and cogency of Edward 
Churchill's remarks more than made up for their 
bre\ity. Churchill, a 1920 graduate of HMS, was 
revered by successive generations of surgical 
house staff at Massachusetts General Hospital, 
where one day a newly manufactured patient 
bed was put on display. Churchill watched as the 
elderly patient, nearly moribund, was twisted 
and turned about as one of the doctors punched 
various buttons. We were all wondering what 
the engineers would be developing next when 
Churchill left the room muttering "Obscene!" 
That one word engraved itself in my mind, 
guarding me against blind infatuation with tech 
nological innovations, a lesson I drew upon 
when I began my work in Shiraz years later. 

But my favorite mentor, by a long shot, was 
Robert "Hawk" Shaw '45. Hawk, I was certain, 
could see around corners. Together we started 
open-heart surgery at Massachusetts General 
Hospital and, as the first pump man there, I had 
become entranced by the emerging technology. 
Yet Bob convinced me that we did not need a cell 
photometer. "The best photometer," he pro- 
claimed, "is already installed in our retina, and 
any surgeon who cannot instantly detect unoxy- 
genated blood should not be operating!" 

The intellectual honesty, moral candor, and 
refreshing humanism of many of the giants of our 
days at HMS lent them an aura of permanency. 
Some of the pearls I would glean from them 
proved invaluable afterward. 

Operating by the Book 

Mohammed Nemazee was a wealthy Iranian 
philanthropist who, in the mid-1950s, had 
donated a large estate in his hometown of Shi 
raz for the construction of the most modern 
150-bed general hospital in that region of the 
world. With loving attention to detail, he had 
created a truly magnificent health care center, 
complete with an adjoining nursing school. It 
had been built, he declared, "for the express 


purpose of introducing modern medical educa 
tion and health care to Iran." 

The hospital lacked nothing in equipment, 
boasting even an iron lung. Allen Whipple, a 
physician born in Iran of American missionary 
parents and imbued with a deep seated love for 
the country, had assumed the presidency of the 
Iran Foundation in New York City and managed 
Nemazee Hospital from a distance. Principal 
clinical positions at the hospital were filled with 
American personnel, because too few Iranian 
specialists were available. Everything looked 
auspicious and the opportunity to help trans- 
plant modern, American style medicine to Iran 
was irresistible. 

Down the road from Nemazee Hospital was a 
100 bed uni\'ersity teaching hospital, Saadi. It had 
been built in early World War II days and, as a 
government supported institution, it had been 
allowed to crumble under the hea\'y burden of hav- 
ing to deliver care to more than four million people. 
When I entered it for the first time, I had the feel- 
ing of being transported back to the Crimean War 
era. Only five glass syringes were available for the 
entire 30-bed surgical ward and not a single naso- 
gastric tube could be found. A sole autoclax'c — 
manufactured in Akron, Ohio, Ln 1926 — stood in a 
corner, still efficiently serving the two dilapidated 
operating rooms, if not the whole hospital. Stan- 
dards of care, I noted with horror, matched the 
physical facUities: every ankle fracture ended up in 
amputation, and records showed that in-hospital 
mortaht)' rates hovered around 30 percent. 

These two health care institutions, separated 
by only one and a half kilometers, were worlds 
apart functionally; while Saadi Hospital was the 
real Iran, Nemazee Hospital represented its 
dream. Yet the chief of surgery at Nemazee Hospi- 
tal was a retired American surgeon who did not 
operate. He spent most of his time chairing com- 
mittees and preparing color- coded chart folders. 
And a younger American surgeon on staff had the 
strange habit of operating with an open book or 
journal propped on a music stand to guide him 
in his dissections. In this manner, he started off 
one early Sunday morning on his first ever 
femoropopliteal b)^ass graft. By about fi\'e in the 
afternoon he called for the Ilth unit of blood. At 
nine that night, it was the surgical resident who 
was frantically calling for the 18th blood unit, 
because the surgeon had left the hospital for Sun- 
day evening prayers at a local missionary church. 

When I raised the issue with our chief of 
surgery a few days later, he explained that our 
young colleague had been gaining experience to 
prepare himself for his thoracic boards. Respect- 

fully I inquired whether this mode of operation 
was ethical, and whether this type of patient 
management would not come under serious 
scrutiny in American medical circles. I was curt- 
ly dismissed with, "This is not America!" 

I next took the matter to another chief of ser- 
\ice, an Iranian specialist who, on the strength of 
his American education, had become our moral 
standard-bearer. His analysis was e\'en more shat- 
tering: "Above all, we must protect the hospital's 
reputation. You had better ignore the whole mat- 
ter. So what if a leg has to come off along the way?" 

That attitude was certainly not in line with 
what Nemazee Hospital had been proclaimed to 
stand for. But I had not been taught at HMS or its 
teaching hospitals how to handle such situations, 
and the nearest center of adjudication was 8,000 
miles away. And supposing I did manage to con 
vey my concerns to the Iran Foundation in New- 
York — ^what could be done? 

Back to the Future 

I resigned from Nemazee Hospital and mo\'ed a 
kilometer and a half down the road, to Saadi Hos 
pital. There I found what e\'ery surgical resident 
dreams of; an unending stream of classical surgical 
cases. Surgical pathology that I thought existed 
only in old textbooks — from Ludwig's angina to 
noma to advanced tuberculosis pericarditis — kept 
coming. And not a single case of colonic divertic 
uhris appeared. My only regret was that I had no 
colleague with whom I could mar\'el at how well 
those conditions responded to treatment. 

I had meant to inaugurate open heart surgery 
in Iran but quickly shelved those plans without 
any quiilms as I busied myself with more mundane 
but just as interesting cUnicd situations. Lacking 
an electric dermatome, for example, I used an old- 
fashioned open razorblade to take freehand skin 
grafts, the way Bradford Cannon 33 had taught me. 

It was Hawk Shaw, howe\er, whom I felt look 
ing over my shoulder. One clay, a few buildings 
away from our hospital, a young student collapsed 
with ventricular fibrillation. The closest defibril 
lator was nearly 2,000 miles away, in Lebanon. But 
Hawk had taught me that all that was needed 
were two broad metal retractors attached to an 



Only five glass syringes were available for the entire 30-bed 
surgical ward and not a single nasogastric tube could be found. 

electric cable that could be plugged quickly into a 
wall socket. It worked! And lo and behold: some 
time later Hawk actually showed up and stayed 
with us for a whole month. 

The greatest accolade I ever received came 
from Cushman Haagensen '23, who, after spend 
ing two weeks with us, wrote me that he "did 
not know of any HMS graduate who had accom- 
phshed so much for his people." I felt like I had 
finally graduated. It was as if I were a red blood 
cell, no longer floating free but inextricably 
caught in a coagulum, that grand structural 
functional-moral design called "medicine." 

But that wonderfully fulfilling professional 
experience could not last Iore\'er; it was pure 
pohtics that uprooted me from Shiraz. Those 
who know the story of "The Emperor's New 
Clothes" will recognize the political settings of 
pre revolutionary Iran. I am certain that the 
Shah meant well for his country. But he could 
not extricate himself from a deeply felt need for 
self aggrandizement. 

And in due course, the Shah appointed a new 
chancellor whose honesty was limited to 
announcing his intention to become the next 
prime minister. He set out to impress and ingrati- 
ate himself with the Shah by ordering the perfor- 
mance of hair-raising transplantation exercises 
strictly for self directed propaganda purposes. 
Ethical considerations meant nothing. I protested 
vehemently. A Faustian agreement was proffered; 
I promptly declined it. 

Nothing in my HMS education could have pre- 
pared me for this experience. I was spared the 
mental anguish of ha\-ing to resign. Yet I had to 
submit to the humihation of being dismissed for 
having openly criticized the authorities. What 
pained me most, howe\'er, was that the motto 
"This is not America" had become too glib an 
excuse, even for those Iranian colleagues who had 
trained in the United States but who now pre- 
ferred to look the other way 

Yet it may ha\e been that particular confronta- 
tion with the establishment in Shiraz that saved 
my neck when the revolution exploded a few 
years later. To be sure, we had our revolutionary 
komitehs — a kind of culture pohce charged with 
enforcing Islamic mores in post- revolutionary 

Iran — and I did carry for quite some time the label 
of a taghooti — a member of the bourgeois class 
despised by the revolutionaries as decadent and 
e\dl — the equi\'alent of an arista from French Rev 
olutionary times. Other than a few years of being 
barred from leaving the country, though, I suffered 
no indignities. In fact, I was allowed to run the 
surgical service at the hospital in southern Tehran. 

As I continue to practice, friends and col 
leagues often me if Iran's medical situation is 
any better now than it was before the revolution. 
My unreservedly affirmative answer to this ques- 
tion is framed by the lessons I learned at HMS so 
many years ago that allowed me to survive the 
last great revolution of the twentieth century. My 
fondness for history, and in particular Persian his- 
tory, tells me that we had to have a revolution to 
wake us up from a 25 -century-long slumber. That 
upheaval was inevitable, as Edward Churchill 
had foreseen when I last met him in his office in 
late 1960, just before I left the United States for 
Iran. It was he who had said, "Developed coun- 
tries have wants, while developing countries have 
needs that must first be met." 

Having gone through interesting and so often 
gripping times, I am not particularly troubled by 
the current trend of international events. Down- 
right humanism and basic good will are still 
everywhere — and plentiful. My survival thus far 
has endowed me with neither any particular 
sociopohtical insights, nor the ability to foresee 
the future of Iran. Given its natural resources, 
however, the most valuable of which is the vast 
number of highly intelligent and dedicated young 
Iranians, we should do well. My own experience 
will not be repeated by anyone, as the situation in 
Iran has changed drastically since my days in Shi- 
raz. And I hope the situation at HMS has not 
changed at all in the interim, with a string of out- 
Standing teachers still forming the core of its edu 
cational mission. ■ 

Farrokh Saidi '54, a retired general and thoracic surgeon, 
continues to teach at the Beheshti University ofMedical 
Science in Tehran. 

Robert "Hawk" Shaw '45 died earlier this year: his obit 
uary can be found on page 63. 

WARD ZONE: Patients 
in the surgical >vard 
of Saadi Hospital in 
1961. The govern- 
ment-supported, 100- 
bed teaching hospital 
was charged >vith 
delivering care to 
more than four mil- 
lion people. 




A physician recalls patient encounters with 

metals — from gold injections to arsenic doses — during 

his seven decades of house calls and hospital visits 





Fifth Avenue Hospital full of chattering youngsters with mild and merely irritating upper 
respiratory infections, some with just the sniffles. Rather than coping with illness of any degree, 
their busy mothers would pack them off to the hospital for a few days. 

Walking into the treatment room on any given morning during a brief surgical stint at 
the hospital in 1934, I would find a row of children with long applicators protruding from each 
nostril. The cotton-tipped ends of the applicators had been dipped in Argyrol — a dork brown 
concentrated silver suspension — and would be left in the nostrils for 15 minutes, several times a 
day. That was the full extent of the children's treatment. They would return home with a prescrip- 
tion for more Argyrol nose drops, to be used for any little cough or cold. 

A few months later, during my internship at Massachusetts General fHospital, we admitted 
a mother and daughter to one of the words. They sat in bed, side by side, their deep blue 
skin scintillating in the bright sunlight streaming through the window. They looked like two 
glitzy blue Martians resting on very white sheets. 

They too had used Argyrol nose drops, and the silver hod entered their bloodstreams, 
turning their skin midnight blue — a silver side effect that would never fade or tarnish. 



off the Top of Their Heads 


suddenly besieged by a host of nearly identical young women. They all wore 
scarves tied around their heads and often sobbed as they complained of headaches 
and nausea. Despite their distress, they displayed strange, expressionless faces. 
When we removed their scarves, we dis- 

covered that they were entirely bald; even 
their eyebrows and eyelashes were miss- 
ing. Some still had axillary and pubic hair; 
a few had a small tuft of the inner eye 
brow left. And their gums \\'ere often a 
peculiar shade of blue. 

We found out that the young ladies had 
all been using a newly launched depilato 
ry prepared wTth thallium acetate. The 
metal rendered the lotion highly cffecti\'e: 
absorbed through the skin into the blood- 
stream, it killed nearly every hair cell it 
reached. Sadly, we had no treatment to 
offer the young women; their hair loss was 
permanent. The state board of health soon 
closed the depilatory company down. 

Babe Magnet 


into my office in Waterloo, Iowa, in 1940. 
"It hurts right here," complained the little 
girl, rubbing her temple just above the 

I checked her carefully. She had neither 
fever nor nasal mucous, her throat was 
normal, her eardrums showed no redness 
or infection. The glands in her neck were 
small and non-tender, and her heartbeat 
was regular. I was about to order a kid- 
ney check when the girl again put her fin- 
ger to her temple and said, "It's .sharp 
right here." 

I focused the beam of my flashlight on 
the spot she fingered. Sure enough, some- 
thing bright glinted in the light, just 
beneath her skin. Using forceps, I pulled 
out an inch-long stainless-steel needle. 
"That's one of my sewing needles!" 
exclaimed the mother. 

"I always keep my needles in the lapel of 
my jacket when I sew," the mother added. 
"Whenever my baby would cry, I would 
cuddle her onto my shoulder until I could 
get her something to eat. Why, that must 
have been five years ago!" 




of a middle-aged man afflicted with severe abdominal cramps and 
repeated vomiting. It was 1936, just as I was beginning my medical 
practice. I was inexperienced, and I wondered why the wife hod chosen me 
instead of their family doctor. 

Given that the man's appendix had been removed years before, his bowel sounds 
were greatly exaggerated, and we were seeing a number of coses of the summer's 
"intestinal flu," gastroenteritis seemed to be the most logical diagnosis. I gave the man 
hypodermic and sat at his bedside until I could be sure that his pain hod subsided. 

Bit by bit, his story emerged, ble was in the midst of divorcing this, his second 
wife, and from the obviously unsympathetic attitude of both the wife and her 
grown daughter by a previous marriage, I could tell that this had been a 
disastrous union. 

Sitting close to the bedroom door, I could hear mother and daughter 
talking across a narrow hallway. "How long will it take?" whispered 
the daughter. "Just a little longer," her mother murmured. 

A few minutes later, just when my hypodermic was beginning to 
take effect, the man gave a sudden cry and died, right before -^*^J^ 

my eyes. We called the undertaker around midnight, and I 
returned home to mull the women's whispers over, struck by 
their businesslike acceptance of the man's death. 

Early the next morning I called the mortician to 
request an autopsy, convinced that arsenic had 
killed my patient. "There's something very odd 
about that family," the mortician said, inter- 
rupting me. "They insisted that we take 
the body to Cedar Rapids lost night and 
have it cremated at once — some 
sort of religious requirenrient, 
they said." 

Almond Joy 


receiving casualties from Omaha Beach. A young cor- 
poral had survived his first operation, during which wc 
had retrieved the bullet that had perforated his small 
bowel just eight or ten inches below his stomach. But 
a fistula had developed through the wound, and we 
watched a trickle of fluid — a mixture of bile, pancreat 
ic juice, and stomach acid — wet down his dressings. 

One of our best surgeons opened the patient up again 
but found a mass of adhesive, distorted anatomy so 
gross that he was forced to back out of the abdomen 
without being able to stop the flow. There the soldier 
lay, losing weight, unable to eat, with a stomach tube 
suctioning and an IV going, day after day. As he contin 
ued to lose electrolytes, he became weaker and weaker. 

Then his stomach tube plugged off, and the only tube 
I had left was a reHc from World War I, with a metal tip 

the size and shape of an almond. The tip was too large to 
go through his nose, so I fed it through his mouth. The 
soldier was by then too weak e\'en to have a gag reflex. 
He was d)'ing. 

The next morning, the ward nurse met me at the door 
and proclaimed, "Corporal Ste\'ens has stopped drain- 
ing!" The last wet dressing had been removed about 
midnight. The wound was dry at last. 

I took another x-ray of the patient's abdomen. It 
showed the almond tip angled at 90 degrees to the tube 
and plugging the fistula from the inside! We left the 
tube in place for another two weeks, administered 
transfusions and more intravenous fluids, and finally 
puUed the tube out carefully. That ancient metal tip had 
saved a young soldier's hfe. 

testified that her lover had shot her 
through the chest from across the 
room, enraged because she hod threatened to 
leave him. He countered that she had been 
creeping up on him v^ith a knife in her hand, 
bent almost to the floor, and he had shot her 
only at the last moment in self-defense. There 
were no witnesses. 

I cared for the woman from the time she was 
brought into the hospital with a sucking wound 
in the apex of her lung. She barely survived. 
Day after day I feared that, despite oxygen 
and repeated transfusions, I could not keep 
her with us. But she lived to file a charge of 
attempted murder. 

During the trial, I testified that we had found 
the bullet lodged against her ischium, at the bot- 
tom of her pelvis. It hod gone from the top of 
her lung, through her chest, then through her 
abdomen. The bullet's trajectory revealed that 
the only way her story could be true was if her 
lover had shot her while clinging to the ceiling. 

The case was ruled for the defendant. He 
did not file suit against her, allowing only, "I 
didn't realize that she hated me so much." 



Donald U: Bidclcv '34 retired in 2001, after 67 years of 
practicin^medkine.primarih' in Waterloo, Iowa. 








by Amalie M. Kass 


woman was in labor with her second child. 
Summoned to her bedside, Walter Chan- 
ning encountered a patient in alarming 
straits. She was hemorrhaging, and the 
physician who had initially been called was 
so intimidated by the possibility of her 
dying that he was afraid to examine her. It 
was up to Channing to determine the cause 
of her bleeding and to terminate her labor. 
Channing found the woman almost 
pulseless, her skin pale and icy, her voice 
feeble, and her overall appearance one of 
extreme exhaustion. His notes reveal the 
gravity of her predicament: "I learned that 
she had been flowing six days; that she had 

lost much blood — by her report, a gallon. 
The case was apparently so hopeless that 
I took the physician and a friend aside 
to prepare them for the worst result that 
might follow the only means which 
promised any good." 

Upon examining the patient, Channing 
discovered the placenta still firmly 
attached to a portion of the cervix. "It was 
at once separated entirely from the uterus, 
and not the least hemorrhage accompanied 
the separation." Channing extracted the 
fetus, already dead for several days, and the 
mother made a good recovery. 

For more than 50 years, Walter Chan- 
ning, who served as dean of Harvard Med- 



ical School for more than two decades, was 
an unnamed presence in the lives of count- 
less Boston women. It was an era when 
women were loath to discuss the realities 
of their pregnancies and deliveries. Yet 
they counted on him to provide as easy and 
safe a labor as possible. His expertise and 
experience, as well as his compassion and 
concern, led to a reputation among his col- 
leagues and patients that has endured into 
the twenty- first century. 

But Channing's story reveals more than 
the practice of obstetrics or the reproductive 
lives of nineteenth-century women. He 
instructed hundreds of young men in "the art 
of midwiferv'" as well as in medical jurispru 

dence, and was instrumental in the creation 
of one of the nation's first lying- in hospitals 
for poor women. His position among the 
small group of physicians who dominated 
medicine in antebellum Boston placed him 
among the most important leaders of the pro- 
fession. In at least one significant change in 
the practice of medicine and obstetrics — the 
use of anesthesia in childbirth — Charming 
was the major force in its acceptance. 

The Home Front 

In eighteenth- and nineteenth-century Amer- 
ica, obstetrics presented difficulties that dis- 
tinguished it from general medical practice. 

In the mid- 1800s, 
decorum dictated 
that male obstetricians 
avert their eyes as 
much as possible 
during patient exams. 
They also often relied 
on female attendants 
to transmit indirectly 
to the patient any 
delicate orders related 
to bodily functions. 



was an era when women were loath to discuss the reahties 
of their pregnancies and dehveries. Yet they counted on 
Channing to provide as easy and safe a labor as possible. 

The nature of childbirth meant that a physician 
could be summoned \\ithout warning at any 
time, day or night, and might have to remain 
with his patient for many hours, even for several 
days. He would attend to the woman at a partic- 
ularly challenging and intimate time, when her 
fears of pain and death were often stronger than 
her hopes for a healthy baby. 

Except for the poor and homeless women 
who gave birth at Boston's lying-in hospital, 
deliveries generally took place in the home of 
the laboring woman. Charming brought his 
basic equipment with him: a female catheter 
sharp scissors and strong thread; lard or oil 
drugs such as belladonna, ergot, and laudanum 
a lancet; and any other instruments he might 
need in an emergency. In time he brought his 
stethoscope, and still later he often had anes- 
thesia with him. 

The largest bedroom was usually set aside for 
the event. Physicians like Channing thought 
that good ventilation was a requisite for health 
and preferred an airy room that was not over- 
heated. A bed would have been prepared, one 
mattress atop another, covered with a piece of 
oiled silk, untanned skin, or layers of blankets. 
If possible, the lower end of the bed was raised 
so that the woman's pelvis would be higher 
than the rest of her body; mattresses were soft 
and Channing wanted to make sure the pelvis 
was well supported. 

Upon his arrival, Channing would find his 
patient fully clothed in loose-fitting garments, 
a cap upon her head. She might have had a 
heavy meal shortly before his arrival. He noted 
one who "had eaten a hearty breakfast of meat 
and potatoes, while labor was present," and 
another who had dined on baked beans and 
huckleberry pie. 

Hard Labor 

Everyone, in the era in which Channing prac- 
ticed, had a friend, mother, or sister who had 
died in childbirth; everyone had a close relative 
whose baby was born dead or died soon after. 
Women feared pregnancy and labor, and some 

even hesitated to marry because they knew 
motherhood would soon be expected of them. 
Channing often reflected on "the death, the sor- 
row, the wide, wide misery" that were part of 
obstetrical practice. 

In negotiating the difficulties associated 
with childbirth, Channing tried to avoid "med- 
dlesome midwifery," a term used in nineteenth- 
century obstetrical textbooks to caution prac- 
titioners against unnecessary interference in 
childbirth, as well as by critics of male physi- 
cians who practiced obstetrics. Yet he could 
and did employ many interventions when need- 
ed. He eased difficult labors with opium or by 
bleeding, both of which appeared to relax the 
patient and gave respite from pain, though 
excessive use might produce a negative effect. 
He tried to stimulate ineffective contractions 
with ergot, though again potential harm could 
result if used inappropriately. 

Channing administered cathartics and ene- 
mas in the belief that they would stimulate con- 
tractions, or as least prevent "costiveness," or 
constipation, a generally feared symptom in 
nineteenth-century medicine. If the cervix 
remained closed, he might try gently dilating it 
with his finger or applying belladonna. If the 
amniotic sac remained intact and seemed to 
impede progress, he punctured it. He usually 
performed this with a sharp fingernail, though 
once he mentioned use of "a large knitting nee- 
dle with a round blunt end," and another time a 
wire. When the fetus was sufficiently low in 
the pelvis, with head first, he employed forceps 
if the patient had greatly weakened. 

When the child presented in a position other 
than headfirst, Channing initially made sure 
spontaneous evolution would not occur, and 
then decided whether he could successfully turn 
the child or if he would have to remove the baby 
by the feet. If he could intervene soon enough, 
he hoped to shorten the labor and save the 
child's life. Turning was excruciatingly painful 
for the mother, and sometimes agonizing also 
for the physician whose hand could be in the 
womb during a strong contraction and might 
be compressed between the fetus and uterus. 



charming used instruments — including for 
ceps, levers, and crochets — as a last resort 
when turning was not possible, the mother's 
life was threatened, or the baby was impacted 
in the peh'is. His primary concern was the safe- 
ty of the mother, even at the expense of the 
child. He usually tried forceps first, but if the 
head remained impacted he sometimes had to 
compress the skull. If the pehic opening pro\'ed 
too small to permit removal of the rest of the 
fetus, he dismembered it, pulling out the parts 
with a blunt hook. 

The decision to use instruments was difficult, 
in part because of possible damage to the moth 
er, the baby, or both, and in part because of the 
horror of such procedures. Until the advent of 
anesthesia in 1846, the mother was conscious. 
Family or friends m attendance had to witness 
the arduous operation. Channing dways sought 
the opinion and assistance of another physician. 
.■\nd before instruments were applied, Chan- 
ning informed the woman directly or through 
attendants. In a few cases she or her family 
refused permission: "I proposed to dehver by the 

forceps. Dr. strongly advised this measure. 

The patient would not permit it. She said she 
was perfectly easy and would sooner die than 
submit to any operation. It was already too late 
and she died in a few hours." 

Numbers Tell the Tale 

The rate of maternal mortality in Channing's 
practice is known for 195 clinical encounters 
described in a list of his midwifery cases from 
1811 to 1822. Two of 18 women who had miscar 
riages died. One was in her fourth month and 
had had a pre\'ious attack of severe dysentery, 
which may have caused the miscarriage and led 
to septic shock or renal failure. The other died 
of convulsions. Of the 177 full-term dehveries, 
eight women died (just over 4 percent), five due 
to infection, and one each to convulsions, 
dysentery, and tuberculosis. In two cases of 
infection the mother recovered. 

The mortality rate among the babies deliv- 
ered in the early years of Channing's practice is 

also known. Forty-one full term babies died 
(nearly 23 percent of the total); 14 were still 
born and 27 died soon after birth. Half the still 
births and infant deaths occurred in the first 
three years of his practice, when he was deliv 
cring primarily poor women. 

The statistics for the rest of Channing's 
practice went unrecorded, though mortality 
rates were likely higher in his practice than in 
those of other physicians, because he was often 
called as a consultant in difficult cases. He 
saved babies with the cord wrapped around 
the neck, slipping it upward as the child 
emerged. He revived stillborn babies by artifi- 
cial respiration, blowing directly into the 
mouth of the child to inflate the lungs and 
stimulate breathing. He also had a system of his 
own that he described for his students, one of 
whom wrote: "Dr. C. says best to have a pipe 
and having this fixed to bellows which will fill 
the lungs. But the inflation must be gradual. 
The quantity of air is very small." 

Channing used external applications as 
well, such as cold water poured over the child, 
to produce respiration. In a few cases of spina 
bifida, he drained fluid accumulating at the 
base of the spine in unsuccessful attempts to 
save the children's lives. 

Boston's leading 
obstetrician, Walter 
Channing v/as known 
for his compassion 
and commitment to 
social justice. 




Channing preferred to wait patiently when labor was 

difficult, recognizing that nature has a way of rectifying 

some situations without assistance. He would turn to the 

use of instruments only as a last resort. 


Born Under Unlucky Stars 

Channing's immersion in the frequently trag 
ic consequences of pregnancy and childbirth 
was not restricted to the realm of the profes- 
sional. In 1822, Channing's wife, Barbara, was 
in the final stages of consumption, spitting 
blood, breathing with difficulty, often beset 
with a violent cough. She was also pregnant 
for the fourth time. She knew that the out- 
look was grim and her husband grew fearful. 
Channing even hoped for a miscarriage, which 
might have relieved the added demands on his 
wife's weakened body. 

Barbara's disease continued to worsen, and 
the final days of her life were almost continu- 
ous suffering. Completely distraught follow- 
ing his wife's death, Channing was unable to 
care for his four small children, including his 
newborn daughter, and unwilling to remain in 
the house where he and Barbara had lived. 
The children were dispersed among relatives. 
Channing continued his professional commit- 
ments, \isittng patients, lecturing at the med- 
ical school, and attending at the hospital. 
Otherwise he spent his time grieving and alone. 

Channing endured a lonely widower's exis- 
tence until, nine years after Barbara's death, he 
married Eliza Watnwright, a woman admired 
for her virtuous character. Eliza quickly 
became "mother" to Channing's four children, 
who were reassembled to live at their father's 
house. Reinvigorated by his expanded house- 
hold, Channing found himself in high spirits. 
Marriage agreed with him and he delighted in 
the ease with which his children had reen- 
tered his life. 

His happiness was augmented when Eliza 
revealed that she was expecting a child. She 
looked toward motherhood "full of hope and 
joy," with no visible anxiety, even though she 
was nearly 40 years old and this was her first 
pregnancy. It was assumed that Channing 
would deliver the baby, as physicians often 
did for their wives in those days. 

Labor began later than anticipated. The 
pains were moderate but continued without 



was devastated. Despite his knowledge of 
obstetrics and years of practice, he had failed to 
save the lives of his own wife and unborn child. 

progress. .-Uthough Eliza became increasingly 
fatigued, Charming did not seem to be alarmed. 
But after three days of unproductive labor, he 
decided to use instruments. He realized that 
the child might be dead, but foresaw no danger 
to his wife. 

Charming insisted on performing the opera- 
tion himself, though wiser heads should have 
counseled against it. Nor did he request assis- 
tance from another physician, as was his stan 
dard practice. As he feared, the child, a boy, was 
dead. But his confidence in Eliza's safety was 
not shaken and it seemed as if the child would 
be the only loss. Within a short while, however, 
Eliza began hemorrhaging. 

Now greatly alarmed, Channing summoned 
James Jackson, his friend and medical mentor. 
But Eliza had already grown very weak. She 
reassured the mournful family around her that 
she was prepared to meet her end. Within haK 
an hour, she was dead. Channing was devastat 
ed. Despite his knowledge of obstetrics and 
years of practice, he had failed to save the lives 
of his own wife and unborn child. 

Unsolved Mysteries 

In the course of his long career, Channing read 
ily admitted his errors. "Mistakes may and have 
been made. And who is not Liable to make 
them?" he once confessed to his students. In 
describing a consultation in which a patient's 
uterus had ruptured and the woman died, he 
said, "I did not examine the abdomen, an over- 
sight I readily acknowledge. I much regret 
omitting this which is often so important a 
means of diagnosis." 

Nor did Channing cling to prevailing social 
notions about pregnancy. He was willing to call 
a baby "prematurely born" to spare its mother 
the embarrassment of a baby conceived before 
marriage, and he once helped a teenage mother 
bury her dead child without public scrutiny, 
"He is a happy physician," he wrote, "who is 
conversant with the causes of things." 

Yet despite his devotion to unearthing "the 
causes of things," Channing found himself fre- 

quently surprised by an unexpected outcome. 
Why had an apparently healthy newborn died? 
Why did a mother experience convulsions dur 
ing delivery? Why did another who seemed to 
be reco\'ering well develop fever and die? He 
was keenly aware of the imperfection of his 
knowledge, of the unanswered questions about 
conception, gestation, labor, and disease that 
remained a great mystery. Postmortem exami- 
nations sometimes explained what had hap- 
pened, but generally not why. 

Channing maintained a lifelong curiosity 
about these kinds of questions. He worked hard, 
often sacrificing his obligations to his own fam- 
ily because he expected a patient to go into labor 
or because he was already engaged in a deli\'ery 
that required many days' attendance. At the age 
of 70 he was stiU staying the night if a case 
required it, still questioning e\ents, still trying 
to understand the mysteries of childbirth. 

Some parts of the riddle were clarified 
during Channing's lifetime, though most 
remained unsolved. He did alter some proce- 
dures according to new ideas about disease and 
therapy. But the fundamentals of obstetrics 
could not change until bacteriology revolution- 
ized the understanding, treatment, and preven- 
tion of infection; endocrinology began to 
explain the development and workings of the 
reproductive system; embryology shed light on 
fetal development; and radiology permitted 
physicians to view the body's interior without 
resorting to mcisions. 

Following his personal devastation by the 
lethal consequences of childbirth, Channing 
found himself, for a time, unable to function as 
a physician. That eventually he did resume 
work and continued, for many long years there- 
after, to care for women threatened by the 
unpredictabihty of pregnancy and delivery is 
testimony to his extraordinary resilience and 
remarkable devotion to his calling. ■ 

Amalk M. Kass is a lecturer on the history of medicine in 
the Department of Social Medicine at HMS. This article 
was adapted from her hook Midwifery and Medi- 
cine in Boston (Northeastern University Press, 2002). 





The Play's the Thing 


^^^M robots dancing the Macarena have in common? They're 
AA^H all interactive toys for disabled children, created by 
Daniel Bogen 76. Bogen found this unusual niche after ten years 
of conducting cardiac mechanics research in the Department of 
Bioengineering at the University of Pennsylvania. 

interactive toys give them opportuni- 
ties for self-expression and recognition 
in the community." 

When Bogen returned from his sabbat- 
ical, he recei\'ed permission to direct the 
bioengineering department's advanced 
design course. With the help of the 30 
or so students in the program, he began 
to develop the toys he had envisioned. 
"We came up with accessible toys that 
were more interesting and challenging 
for kids with limited use of their hands 
and fingers," Bogen says. "That was 
the beginning." 

Bogen remembers one of his earUest 
creations, a fuzzy stuffed doU knowTi as 
the "Crazy Purple Guy." Bogeris team 
had designed the toy with a switch in 
each foot. Press one switch, and the pur- 
ple creature giggled; press another, and 
he gyrated. One of the children who test- 
ed the toy was an eight year- old 
boy with cerebral palsy. 

"I was concerned that cardiac mechan- 
ics would lead me into more and more 
invasive technology," Bogen says. So he 
took a sabbatical to figure out how best 
to use his abilities to help people — the 
reason he'd been drawn to medical 
school in the first place. On a tour of 
Childreris Seashore House, a pediatric 
rehabilitation facility that is now part 
of The Children's Hospital of Philadel- 
phia, he saw a need for his engineering 
expertise when he watched disabled 
children playing with toys that per- 
formed simple, repetitive actions. 

"If you're three years old, a monkey 
banging cymbals might be fun for a 
while," Bogen says, "but I realized we 
could do better than that. Many severe- 
ly disabled children are at risk for 
developing a secondary disability; 
social isolation. Their primary disabili- 
ty cuts them off from many expres- 
sive and social activities, and 

This two-minute 
timer helps children 
v«^ith neurobehavioral 
impairments, such as 
those related to head 
injuries or attention deficit 
hyperactivity disorder, 
stay focused. 

"The boy could barely move his hands 
against gra\ity, maybe an inch off the 
table," Bogen says. "But he lifted his httle 
hand and touched one big purple foot 
and the toy reacted to him by making a 
laughing sound; then the boy lifted his 
other hand and pressed the other foot 
and the toy shook." Bogen watched as 
the boy played, delighted, because no toy 
had e\'er responded to him in that way. 

"That was the key moment," Bogen 
says. "That's when I decided: I'm going 
to stay in this. Since then I've tried to 
produce toys that are both wonderful 
and useful." 

Bogen collects information about the 
technologies used in consumer products, 
which he files away alongside his knowd- 
edge of pediatric medical problems and 
ideas for possible solutions. "Often I can 
\isualize the pediatric problem, but not 
the design solution," Bogen says. "Or I can 
emision a design for a new t)'pe of toy, 
but not its use. I keep adding and stirring 
the pot. I might \isit a colleague at Chil- 
dreris Hospital and see a six-year-old 
girl who's quadriplegic — and suddenly, 
there's the application for a design I had 
filed away. Or I might read an electronic 
trade journal and discover a new- 
chip — and there's the way for me 
to build a toy r\e been mulling over 
for several years." 

The next phase is build 
ing a prototype and show- 
ing it to doctors, thera- 
pists, patients, and families. 
"Usually, until we build the prototype, 
nobody has any idea of what we're talk- 
ing about," Bogen says. "Once they see 
it, and we all test it out a bit, we realize 
the possibilities." 

The major project in Bogeris laborato 
ry this year is a de\ice called TiltMagic, 
which employs a tilt sensor worn on 
cither the head or body to help diagnose 
and treat neuromuscular disorders. But 
Bogen and his team also used this tech- 
nology to create robots that a disabled 
child can manipulate. Ln the most basic 



"If you're three years old, a monkey banging cymbals 
might be fun for a while, but I realized we could do better 
than that. Many severely disabled children are at risk 
for developing a secondary disability: social isolation." 

application, the senseir is worn on the 
head; tilting the head forw^ard makes the 
robot walk forward; tilting the head back 
makes it back up. "In a more challenging 
program," Bogen says, "each tilt of the 
head makes the robot take a single step; 
left tilt, left step; right tilt, right step." 
The more advanced programs allow the 
child to make the robots dance, Bogen 
adds. "They can do the electric shde, the 
Macarena, and the cha-cha." 

The toys can be used as training aids 
as well. "Our robot can be used as a 
flight simulator for a child who will 
eventually use a head controlled wheel 
chair," Bogen says. "There's no penalty 
for crashing the robot, while there is a 
fairly big penalty when a child crashes a 
powered wheelchair." 

Bogen and his team have also devel 
oped a unique device for children with 
neurobehavioral impairments, such as 
those related to head injuries or atten- 
tion deficit hyperactivity disorder. This 
simple ladybug timer helps children 
stay focused and make transitions 
between tasks. Before beginning a play 
activity or chore, the child picks up the 
ladybug to start timing. Two minutes 
later, time is up, and the toy "bugs" the 
child by beeping. 

One project Bogen is excited about 
invoh'es developing musical instruments 
for children with physical cUsabilities. 
Although these children may be able to 
use only their head or have limited arm, 
hand, or leg motion, the instruments 
v\ould allow them to produce music. 

"The idea is for them to be able to 
control sounds, meter, pitch, and 
rhythm — and really get into the 
music," Bogen says. It's one of his 
more ambitious projects, and one 
that he will subject to the most rig 
orous examination — the daughter 
test. Before making it into the hands 
of eager children, the toys must pass 
muster with his teenagers, Rachel, Clare, 
and Alice, who routinely weigh in on 
their father's projects. 

"They tell me whether an idea is 
'cool" or 'boring,' which is the most 
important information I can get," Bogen 
says. "From them I've learned that play 
is serious business." 

Bogen says that it's difficult to com- 
mercialize the toys he makes, given the 
limited market for such specialized 
items. He has been considering forming 
a nonprofit organization to manufac- 
ture the toys and then donate them to 
disabled children. "The whole area of 
funding has been vexing," he says. "We 
fall into a financial no-man's land." 

The real payoff, however, comes from 
giving the toys to children who haven't 
had enough opportunities to play. 

"We're trying to take all the wonder- 
ful resources of consumer product devel- 
opment and focus them on the needs of 
sick and disabled children, to address 
the little things — not so httle, really — 
that add up to a child's quality of life." ■ 

Susan Cassidy is assistant editor of the Harvard 
Medical .Alumni Bulletin. 

PUPPET MASTERY: Equipped with 
electronic controls, this jellyfish 
will be one character in an ani- 
matronic puppet theater that 
Daniel Bogen is now develop- 
ing. Using head movements, a 
quadriplegic child will be able to 
make the jellyfish wiggle its ten- 
tacles and roll its eyes. 

of what's important in the lives 
of children came from vt^atching 
my own kids grow up." 



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